
Class. 
Book.. 



-58 



Copyright^?. 



1909 



COPYRIGHT DEPOSIT. 



BOOKS 

BY 

ARTHUR A. STEVENS, M.D. 



Modern Materia Medica and 
Therapeutics 

Octavo of 675 pages. Cloth, 
#3.50 net. Fifth Edition 



Practice of Medicine 

121110 of 556 pages, illustrated. 
Flexible leather, $2. 50 net. 
Eighth Edition 



MODERN 



MATERIA MEDICA 



AND 



THERAPEUTICS 



BY 

A. A. STEVENS, A.M., M.D. 

|1 

Professor of Therapeutics and Clinical Medicine, Woman's Medical College of 
Pennsylvania ; Lecturer on Physical Diagnosis in the University of Penn- 
sylvania ; Physician to the Episcopal Hospital and to St. Agnes's 
Hospital ; Assistant Physician to the Philadelphia General Hos- 
pital ; Fellow of the College of Physicians of Philadelphia, etc. 



ffittb Bfcitfon, Uborou0bl£ IRexnsefc 

In Conformity witb tbe EiQbtb "Revision (1905) of tbe 
THniteo States pbarmacopoeia 



PHILADELPHIA AND LONDON 

W. B. SAUNDERS COMPANY 

1909 






id 4 

(SEP 


^ I90b> 
3 1909 



Set up, electrotyped, printed, and copyrighted March, 1894. Revised, reprinted 
and recopyrighted June, 1895. Revised, entirely reset, reprinted, and 
recopyrighted May, 1903. Reprinted July, 1904. Revised, 
reprinted, and recopyrighted November, 1905. Re- 
printed June, 1906, and April, 1907. Revised, 
reprinted, and recopyrighted August, 1909. 



Copyright, 1909, by W. B. Saunders Company. 



AUTHORITY TO USE FOR COMMENT THE PHARMA" 
COPOEIA OF THE UNITED STATES OF AMERICA, EIGHTH 
DECENNIAL REVISION, IN THIS VOLUME. HAS BEEN 
GRANTED BY THE BOARD OF TRUSTEES OF THE 
UNITED STATES P H A R M A C O PO E I A L CONVENTION, 

WHICH BOARD OF TRUSTEES IS IN NO WAY RESPONSIBLE 
FOR THE ACCURACY OF ANY TRANSLATIONS OF THE 
OFFICIAL WEIGHTS AND M EASU RES, OR FOR ANY STATE- 
MENTS AS TO STRENGTH OF OFFICIAL PREPARATIONS 



PRINTED IN AMERICA 



PRESS OF 
SAUNDERS COMPANY 
PHILADELPHIA 



PREFACE TO THE FIFTH EDITION. 



This edition has been thoroughly revised, and contains 
many important modifications and considerable additions. 
The section dealing with the Action and Uses of Drugs 
has been in large part rewritten. Articles dealing with a 
number of new remedies have been incorporated, and new 
formulae have been added where it was thought they would 
make more clear the therapeutic application of the drugs 
under consideration. The author ventures to hope that the 
work in its present form may be found equal to existing 
requirements, and that it may prove as acceptable to 
students of medicine as former editions. 

314 S. Sixteenth Street, Philadelphia, 
August, 1909. 



PREFACE TO THE FOURTH EDITION. 



The fourth edition of this work has been thoroughly revised 
and adapted to the Eighth Decennial Revision of the United- 
States Pharmacopeia. Such corrections and additions have 
been made as seemed necessary to make it a more complete 
guide to the study of Materia Medica and Therapeutics. New 
articles, dealing with Scopolamin, Ethyl-chlorid, Theocin, Ver- 
onal, and Radium have been introduced, and in the section on 
Radiotherapy much new matter has been incorporated. 

Among the many changes to be found in the new Pharma- 
copoeia, attention is especially called to the following : The 
tincture of aconite has been reduced in strength from 35 per 
cent, to 10 per cent., and the tincture of veratrum from 40 per 
cent, to 10 per cent. The tinctures of strophanthus and can- 
tharides have each been increased in strength from 5 per cent. 
to 10 per cent. The tincture of nux vomica now contains 0.1 
per cent, instead of 0.3 per cent, of strychnin. 

Blue ointment and mercurial ointment are no longer synony- 
mous. The former (Unguentum Hydrargyri Dilutum) now 
contains about 33.5 per cent, of metallic mercury, while mer- 
curial ointment contains about 50 per cent. — which was for- 
merly the strength of blue ointment. 

The most noteworthy additions to the Pharmacopoeia are 
Acetphenetidum (phenacetin), ^Ethylis Carbamas (urethane), 
^Ethylis Chloridum (ethyl-chlorid), Antipyrina (antipyrin), 
Bromoformum (bromoform), Cresol, Gelatinum (gelatin), Glan- 
dulae Suprarenales Siccae (desiccated suprarenal glands), Glan- 
dulae Thyroidese Siccae (desiccated thyroid glands), Guaiacol, 
Guaiacolis Carbonas (guaiacol carbonate), Hexamethylenamina 
(hexamethylenamin or urotropin), Iodolum (iodol), Liquor 
Formaldehydi (solution of formaldehyde), Methylthioninae 



10 PREFACE TO THE FOURTH EDITION. 

Hydrochloridum (methylene blue), Pelletierinae Tannas (pel- 
letierin tannate), Scopolamine Hydrobromidum (scopolamin 
hydrobromid), Serum Antidiphthericum (diphtheria antitoxin), 
Strontii Salicylas (strontium salicylate), Sulphonethylmethanum 
(trional), Sulphonmethanum (sulphonal), and Thymolis Iodi- 
dum (thymol iodide or aristol). 

A number of compound preparations have been introduced 
as substitutes for commercial articles of a similar, but less defi- 
nite, composition. The chief of these are Cataplasma Kaolini 
(cataplasm of kaolin, or white clay), Fluidextractum Rhamni 
Purshianae Aromaticum (aromatic fluidextract of cascara 
sagrada), Liquor Antisepticus (antiseptic solution), Liquor 
Cresolis Compositus (compound solution of cresol), Pulvis 
Acetanilidi Compositus (compound acetanilid powder), and 
Vinum Cocae (wine of coca). 

The titles of a number of official articles have been changed. 
Thus, all Extracta Fluida have been changed to Fluidextracta. 
Instead of writing, for example, Extracti Ergotae Fluidi, one 
now writes Fluidextracti Ergotae. Hydrochloridum has been 
substituted for Hydrochloras, Hydrobromidum for Hydro- 
bromas, Valeras for Valerianas, Arseni Trioxidum for Acidum 
Arsenosum, Phenol for Acidum Carbolicum, Chloralum Hy- 
dratum for Chloral, Betanaphthol for Naphtol, Potassii Hy- 
droxidum for Potassa, Resorcinol for Resorcinum, Spiritus 
Glycerylis Nitratis for Spiritus Glonoini, and Veratrum for 
Veratrum Viride. 



CONTENTS 



MATERIA MEDICA. 

PAOK 

General Considerations . 17 

Composition of Drugs 18 

Preparations of Drugs 19 

Incompatibility in Prescriptions 30 

Methods of Administering Drugs 35 

By the Mouth 35 

Hypodermic Method 35 

Intravenous Injection 36 

By the Rectum 36 

Inunction 36 

Endermic Method 37 

Fumigation 37 

Inhalation 37 

Circumstances Modifying the Effect of Drugs 37 

Circumstances Modifying the Effect of Dosage 38 

Drugs , 39 

Circulatory Stimulants 39 

Increase of Blood Pressure 39 

Acceleration of the Heart-heat , 40 

Circulatory Depressants „ 59 

Reduction of Blood Pressure 59 

Reduction of Pulse-rate „ . " . 60 

Vasoconstrictors and Vasodilators . ' . . . ^ 66 

Respiratory Stimulants , 73 

Respiratory Depressants 74 

Cerebral Excitants . » 74 

Cerebral Depressants 89 

Somnifacients 90 

General Anesthetics 118 

General Analgesics or Anodynes 130 

Anticonvulsants 130 

Antispasmodics 131 

Spinal Cord Excitants 140 

Spinal Cord Depressants 145 

Motor Nerve Depressants 150 

Sensory Nerve Depressants 153 

Mydriatics 161 

Myotics . « 165 

Emetics 166 

11 



1 2 CONTENTS. 

PAGE 

Anti-emetics x 5g 

Gastric Antacids j« 

Stomachics I7 . 

Digestants l8o 

Carminatives !3^ 

Cathartics jq. 

Diuretics 220 

Stimulants to the Genito-urinary Tract 233 

Sedatives to the Genito-urinary Tract 242 

Uric-acid Solvents 2 ^-> 

Aphrodisiacs and Anaphrodisiacs 244 

Emmenagogues 247 

Oxytocics, or Ecbolics 252 

Diaphoretics, or Sudorifics 257 

Antihydrotics 262 

Expectorants 266 

Sedative Expectorants 269 

Stimulant Expectorants 275 

Tonics 289 

Alteratives 305 

Desiccated Thyroid Glands 341 

Thymus Gland 344 

Pituitary Body 345 

Testis and Ovarium 34c 

Antipyretics or Febrifuges 346 

Astringents 353 

Hemostatics 377 

Germicides, Antiseptics, and Deodorizers 383 

Antimalarials 414 

Anthelmintics 422 

Antitoxins and Vaccines 428 

Irritants and Counterirritants 438 

Escharotics or Caustics 447 

Protectives . x 458 

Flavoring Agents , 469 

Remedial Measures Other than Drugs 475 

Electricity 475 

Massage 4^4 

Movement Therapy for Locomotor Ataxia 4^6 

The Schott or Nauheim Treatment 4^8 

Application of Cold 49° 

Application of Heat 493 

Hypodermoclysis and Infusion 49^ 

Enteroclysis 49^ 

Lavage of the Stomach 5°° 



CONTENTS. 1 3 

PAGE 

Bloodletting 501 

Cupping 5 QI 

Leeching 5 02 

Venesection or Phlebotomy 503 

Actinotherapy 504 

Rontgen Ravs 505 

Radium 506 

Lumbar Puncture 507 

APPLIED THERAPEUTICS- 

Acute Infectious Diseases 5°9 

Typhoid Fever, 509 — Typhus Fever, 514 — Relapsing Fever, 514 — Cere- 
brospinal Fever, 515 — Malarial Fever, 516 — Influenza, 517 — Croup- 
ous Pneumonia, 519 — Diphtheria, 523 — Scarlet Fever, 525 — Measles 
and Rubella, 527 — Small-pox, 528 — Yellow Fever, 530 — Cholera, 
531 — Whooping-cough, 532 — Erysipelas, 534 — Tetanus, 535 — Rheu- 
matic Fever, 536 — Mumps, 538. 

Constitutional Diseases 539 

Diabetes Mellitus, 539 — Diabetes Insipidus, 542 — Gout, 542 — Chronic 
Rheumatism, 544 — Muscular Rheumatism, 545 — Rheumatoid Arthri- 
tis, 545 — Rachitis, 546. 

Diseases of the Blood and Ductless Glands . . . 547 

Chlorosis, 547 — Pernicious Anemia, 547 — Leukemia, Pseudoleukemia, and 
Splenic Anemia, 548 — Scurvy, 548 — Purpura Haemorrhagica, 549 — 
Hemophilia, 549 — Addison's Disease, 549 — Myxedema, 550 — Ex- 
ophthalmic Goiter, 550. 

Diseases of the Digestive Tract 55 1 

Stomatitis, 551 — Acute Pharyngitis, 552 — Chronic Pharyngitis, 553 — 
Acute Tonsillitis, 553 — Acute Catarrhal Gastritis, 554 — Indigestion, 
555— Gastralgia, 558 — Gastric Ulcer, 559 — Gastric Cancer, 561 — 
Dilatation of the Stomach, 562 — Chronic Constipation, 563 — Acute 
Diarrhea, 565 — Chronic Diarrhea, 568 — Dysentery, 569 — Appendi- 
citis, 571 — Catarrhal Hepatitis, 572 — Cholelithiasis, 573 — Cirrhosis 
of the Liver, 575. 

Diseases of the Respiratory System 577 

Acute Rhinitis, 577 — Chronic Rhinitis, 578 — Atrophic Rhinitis, 579 — 
Acute Laryngitis, 580 — Spasmodic Croup, 580 — Chronic Laryngitis, 
581 — Tuberculous Laryngitis, 582 — Syphilitic Laryngitis, 583 — 
Acute Bronchitis, 584 — Chronic Bronchitis, 585 — Asthma, 587 — 
Emphysema, 590 — Catarrhal Pneumonia, 591 — Pulmonary Tubercu- 
losis, 592 — Pleurisy, 601 — Empyema, 604. 



14 CONTENTS. 

PAGE 

Diseases of the Circulatory System 604 

Pericarditis, 604 — Acute Endocarditis, 606 — Chronic Endocarditis, 607 — 
Chronic Myocardial Disease, 613 — Angina Pectoris, 615. 

Diseases of the Kidneys 616 

Acute Nephritis, 616 — Chronic Nephritis, 618 — Nephrolithiasis, 622. 

Diseases of the Nervous System 624 

Acute Cerebral Leptomeningitis, 624 — Cerebral Hemorrhage, 624 — Loco- 
motor Ataxia, 625 — Myelitis, 627 — Poliomyelitis, 628 — Neuritis, 629 
— Sciatica, 630 — Neuralgia, 631 — Chorea, 634 — Epilepsy, 635 — 
Neurasthenia, 639 — Hysteria, 642. 

Weights and Measures 644 

Index ....... 647 



MODERN 
MATERIA MEDICA 



AND 



THERAPEUTICS 



Modern 
MATERIA MEDICA AND THERAPEUTICS. 



GENERAL CONSIDERATIONS. 

Materia medica is that branch of medical science which 
treats of the remedies used in medicine. It deals with their 
sources, physical characters, composition, preparations, and 
doses. 

Pharmacy is the art of preparing, compounding, and dis- 
pensing medicines. 

Pharmacodynamics is the study of the action of drugs 
upon living organisms. Our knowledge of the action of 
drugs upon human beings is obtained in two ways : First, by 
clinical experience, and secondly, by comparative study of 
their action on the lower animals. 

Therapeutics is that branch of medicine which deals with 
the application of remedies to disease. In its broadest sense, 
it has to do not onlv with dru^s, but with all other agents 
which are of service in restoring health, prolonging life, or 
affording comfort to the sick. 

Treatment based solely on clinical experience, and instituted 
without reference to the physiologic action of the remedies 
employed, constitutes empirical therapeutics. Thus, the giv- 
ing of opium in diabetes and of salicylic acid in rheumatism, 
simply because experience has taught that these drugs often 
do good, are illustrations of empirical therapeutics. 

The treatment of disease by drugs which are expected, from 
a knowledge of their physiologic actions, to antagonize cer- 
tain known pathologic conditions, constitutes rational thera- 
peutics. The employment of chloral in the convulsions of 
tetanus maybe cited as an illustration of rational therapeutics, 
since it is expected that chloral, through its sedative effect, will 
counteract the spinal irritation which is manifesting itself in 
convulsions. 

COMPOSITION OF DRUGS. 

The composition of the inorganic drugs is indicated by their 
names and formulas. The composition of the organic drugs is 
often exceedingly complex. They may contain fixed oils, 
2 17 



1 8 GENERAL CONSIDERATIONS. 

volatile or essential oils, resins, oleoresins, balsams, gums, 
gum-resins, alkaloids, glucosids, saponins, neutral principles, 
and organic acids. 

Stereoptenes are the solid oxidized products which certain 
volatile oils yield when they are cooled sufficiently or are al- 
lowed to stand. Camphor, thymol, and menthol are examples. 

Fixed oils are oils obtained by simple pressure, and are 
not readily volatilized. Croton oil, cod-liver oil, castor oil, and 
olive oil are examples of fixed oils. 

Volatile or essential oils are obtained chiefly by dis- 
tillation. They give the peculiar odor and taste to plants. 
Oils of cinnamon, turpentine, mint, eucalyptus, juniper, cloves, 
copaiba, and lemon are volatile oils. 

Resins are exudations allied to and probably derived from 
volatile oils. They are oxidized hydrocarbons, amorphous, 
brittle, insoluble in water, but freely soluble in alcohol. They 
unite with alkalies to form soaps. They melt at a low heat, 
and solidify again on cooling. The chief official resins are 
those of copaiba, jalap, podophyllum, scammony, and guai- 
acum-wood. 

Oleoresins are stable mixtures of a volatile oil and a 
resin. Their two constituents can be separated by distillation. 
The oleoresins used in medicine are those of aspidium, capsi- 
cum, cubeb, lupulin, ginger, and black pepper. 

Balsams are resins or oleoresins containing benzoic acid 
or cinnamic acid. The chief balsams are those of peru, tolu, 
and storax. 

Gums are desiccated exudations obtained by incising the 
limbs and branches of certain plants. They form a mucilage 
or jelly with water, and are insoluble in alcohol. The most 
important gums are those of acacia and tragacanth. 

Gum-resins are mixtures of gum with resins or oleo- 
resins. Asafetida, ammoniac, myrrh, gamboge, and scammony 
are examples of gum-resins. 

Alkaloids are nitrogenous compounds occurring in plants, 
resembling ammonia in being basic and capable of forming 
salts with acids. In many instances, as in the case of atropin, 
morphin, aconitin, and quinin, the alkaloid represents to a 
great extent the active properties of the drug. 

Glucosids are compounds which, treated with mineral 
acids or certain ferments, are resolved into two or more sub- 
stances, one of which is glucose. They may be either neutral 
or acid in reaction, and nearly all are soluble in alcohol. The 
chief glucosids are arbutin, amygdalin, glycyrrhizin, convalla- 
marin, adonidin, digitalin, digitoxin, and strophanthin. 



PREPARATIONS OF DRUGS. 1 9 

Saponins are non-nitrogenous bodies, generally glucosids, 
which possess the property of foaming with water, emulsifying 
fats, and laking the red blood-cells. They are found in a 
number of plants, especially soap-bark, sarsaparilla, and senega. 
They are not absorbed from the intact alimentary canal, but 
have an intensely irritant local action. 

Neutral principles are neutral or feebly acid constituents 
of plants, differing from glucosids in not being resolvable into 
glucose, and from alkaloids in not being precipitated by tannic 
acid or mercuric potassium iodid. Aloin, elaterin, santonin, 
picrotoxin, salicin, and chrysarobin belong to this class of 
compounds. 

Organic Acids. — Many vegetable drugs contain organic 
acids, either free or combined with alkaloids or inorganic 
bases. The organic vegetable acids of most value in medicine 
are gallic, tannic, salicylic, benzoic, citric, acetic, and tartaric 
acids. 

PREPARATIONS OF DRUGS. 

Vinegars (aceta) are liquid preparations made by treating 
vegetable drugs with diluted acetic acid. Only two are official : 

Acetum Opii (vinegar of opium). 

Acetum Scillae (vinegar of squill). 

Waters (aquae) are aqueous solutions of volatile sub- 
stances. The waters most commonly used are : 

Aqua Ammonise (water of ammonia). 

Aqua Ammoniae Fortior (stronger water of ammonia). 

Aqua Anisi (anise-water). 

Aqua Aurantii Florum (orange-flower water). 

Aqua Camphorae (camphor-water). 

Aqua Chloroformi (chloroform-water). 

Aqua Cinnamomi (cinnamon-water). 

Aqua Fceniculi (fennel-water). 

Aqua Hamamelidis (hamamelis-water). 

Aqua Hydrogenii Dioxidi (solution of hydrogen dioxid). 

Aqua Menthae Piperita^ (peppermint-water). 

Aqua Rosae (rose-water). 

Solutions (liquores) are solutions of non-volatile substances 
in water. The official solutions contain only inorganic salts. 
Among the most important of this class of preparations are : 

Liquor Acidi Arsenosi (solution of arsenous acid). 

Liquor Ammonii Acetatis (solution of ammonium acetate, 
spirit of Mindererus). 

Liquor Arseni et Hydrargyri Iodidi (solution of arsenous 
and mercuric iodids, Donovan's solution). 



20 GENERAL CONSIDERATIONS. 

Liquor Calcis (solution of calcium hydroxid, lime-water). 

Liquor Chlori Compositus (compound solution of chlorin). 

Liquor Ferri et Ammonii Acetatis (solution of iron and 
ammonium acetate, Basham's mixture). 

Liquor Ferri Subsulphatis (solution of ferric subsulphate, 
Monsel's solution). 

Liquor Formaldehydi (solution of formaldehyde). 

Liquor Iodi Compositus (compound solution of iodin, 
Lugol's solution). 

Liquor Magnesii Citratis (solution ot magnesium citrate). 

Liquor Plumbi Subacetatis Dilutus (diluted solution of lead 
subacetate, lead-water). 

Liquor Potassii Arsenitis (solution of potassium arsenite, 
Fowler's solution). 

Liquor Potassii Citratis (solution of potassium citrate, neu- 
tral mixture). 

Liquor Potassii Hydroxidi (solution of potassium hydroxid). 

Liquor Sodii Hydroxidi (solution of sodium hydroxid). 

Decoctions (decocta) are liquid preparations made by boil- 
ing vegetable drugs for fifteen minutes in a closely covered 
vessel, allowing to cool, and then straining. They should be 
freshly prepared, since they readily decompose. There are no 
official decoctions. 

Infusions (infusa) are liquid preparations made by adding 
to vegetable substances hot or cold water, allowing the mix- 
ture to stand for a certain period, and then straining it. The 
large dose and the tendency to decompose are disadvantages. 
The official infusions are : 

Infusum Digitalis (infusion of digitalis). 

Infusum Pruni Virginians (infusion of wild cherry). 

Infusum Sennae Compositum (compound infusion of senna, 
black draught). 

Mixtures (misturae) are liquid preparations holding in sus- 
pension medicinal substances. In some mixtures mucilage or 
syrup is used to prevent rapid precipitation of the insoluble 
substance. Mixtures should be well shaken before being ad- 
ministered. The official mixtures are : 

Mistura Cretae (chalk mixture). 

Mistura Ferri Composita (compound iron mixture, Griffith's 
mixture). 

Mistura Glycyrrhizae Composita (compound mixture of 
glycyrrhiza, brown mixture). 

Mistura Rhei et Sodae (mixture of rhubarb and soda). 

Mucilages (mucilagines) are aqueous solutions of gums or 
other mucilaginous substances. They are used as emollients, 



PREPARATIONS OF DRUGS. 21 

as excipients for pills, and for suspending insoluble substances 
in liquids. The official mucilages are : 

Mucilago Acacias (mucilage of acacia). 

Mucilago Sassafras Medullas (mucilage of sassafras pith). 

Mucilago Tragacanthae (mucilage of tragacanth). 

Mucilago Ulmi (mucilage of elm). 

SyrupS (syrupi) are concentrated aqueous solutions of sugar 
containing medicinal or flavoring agents. The official syrups 
in most common use are : 

Syrupus Acacias (syrup of acacia). 

Syrupus Acidi Citrici (syrup of citric acid). 

Syrupus Acidi Hydriodici (syrup of hydriodic acid). 

Syrupus Aurantii (syrup of orange). 

Syrupus Calcii Lactophosphatis (syrup of calcium lacto- 
phosphate). 

Syrupus Ferri Iodidi (syrup of ferrous iodid). 

Syrupus Ferri, Quininae, et Strychninae Phosphatum (syrup 
of the phosphates of iron, quinin, and strychnin). 

Syrupus Hypophosphitum (syrup of hypophosphites). 

Syrupus Hypophosphitum Compositus (compound syrup 
of hypophosphites). 

Syrupus Ipecacuanhae (syrup of ipecac). 

Syrupus Lactucarii (syrup of lactucarium). 

Syrupus Pruni Virginianae (syrup of wild cherry). 

Syrupus Rhei (syrup of rhubarb). 

Syrupus Rhei Aromaticus (aromatic syrup of rhubarb). 

Syrupus Sarsaparillae Compositus (compound syrup of sar- 
saparilla). 

Syrupus Scillae (syrup of squill). 

Syrupus Scillae Compositus (compound syrup of squill, 
Coxe's hive syrup). 

Syrupus Senegas (syrup of senega). 

Syrupus Tolutanus (syrup of tolu). 

Syrupus Zingiberis (syrup of ginger). 

Simple syrup (Syrupus) consists of water and 85 per cent, 
(by volume) of sugar. 

Elixirs (elixiria) are sweetened aromatic alcoholic prepara- 
tions. The official elixirs are : 

Elixir Adjuvans (adjuvant elixir). 

Elixir Aromaticum (aromatic elixir). 

Elixir Ferri, Quininae et Strychninae Phosphatum (elixir of 
iron, quinin, and strychnin phosphates). 

Spirits (spiritus) are alcoholic solutions of volatile sub- 
stances. The most important spirits are : 



22 GENERAL CONSIDERATIONS. 

Spiritus ^Etheris Compositus (compound spirit of ether, 
Hoffmann's anodyne). 

Spiritus Athens Nitrosi (spirit of nitrous ether). 

Spiritus Ammoniae (spirit of ammonia). 

Spiritus Ammoniae Aromaticus (aromatic spirit of ammonia). 

Spiritus Camphorae (spirit of camphor). 

Spiritus Chloroformi (spirit of chloroform). 

Spiritus Cinnamomi (spirit of cinnamon). 

Spiritus Frumenti (whisky). 

Spiritus Glycerylis Nitratis (spirit of glyceryl trinitrate, spirit 
of glonoin, spirit of nitroglycerin). 

Spiritus Juniperi Compositus (compound spirit of juniper). 

Spiritus Lavandulae (spirit of lavender). 

Spiritus Menthae Piperitae (spirit of peppermint). 

Spiritus Vini Gallici (brandy). 

Tinctures are alcoholic or hydro-alcoholic solutions of 
non-volatile (except iodin) substances. They are made by 
simple solution, maceration, percolation, or maceration and 
percolation. They are not so strong as the fluid extracts, and, 
unlike the latter, they are not all of the same definite strength. 
Most of the tinctures are made with water and alcohol, but 
some are made with undiluted alcohol. The following are 
among the most important tinctures that are made with 
alcohol and water : 

Tinctura Aconiti (tincture of aconite). 

Tinctura Aurantii Amari (tincture of bitter orange peel). 

Tinctura Belladonnas Foliorum (tincture of belladonna 
leaves). 

Tinctura Calumbae (tincture of calumba). 

Tinctura Capsici (tincture of capsicum). 

Tinctura Cardamomi Composita (compound tincture of 
cardamom). 

Tinctura Cinchonae (tincture of cinchona). 

Tinctura Cinchonae Composita (compound tincture of cin- 
chona, Huxham's tincture). 

Tinctura Colchici Seminis (tincture of colchicum seed). 

Tinctura Digitalis (tincture of digitalis). 

Tinctura Gambir Composita (compound tincture of gambir). 

Tinctura Gelsemii (Tincture of gelsemium). 

Tinctura Gentianae Composita (compound tincture of 
gentian). 

Tinctura Guaiaci Ammoniata (ammoniated tincture of 
guaiac). 

Tinctura Hyoscyami (tincture of hyoscyamus). 

Tinctura Kino (tincture of kino). 



PREPARATIONS OF DRUGS. 23 

Tinctura Krameriae (tincture of krameria). 

Tinctura Lavandulae Composita (compound tincture of 
lavender). 

Tinctura Lobeliae (tincture of lobelia). 

Tinctura Nucis Vomicae (tincture of nux vomica). 

Tinctura Opii (tincture of opium, laudanum). 

Tinctura Opii Camphorata (camphorated tincture of opium, 
paregoric). 

Tinctura Opii Deodorati (tincture of deodorized opium). 

Tinctura Quassiae (tincture of quassia). 

Tinctura Rhei (tincture of rhubarb). 

Tinctura Stramonii Seminis (tincture of stramonium seed). 

Tinctura Strophanthi (tincture of strophanthus). 

Tinctura Valerianae Ammoniata (ammoniated tincture of 
valerian). 

The following official tinctures are made with undiluted 
alcohol : 

Tinctura Asafcetidae (tincture of asafetida). 

Tinctura Aurantii Dulcis (tincture of sweet orange-peel). 

Tinctura Benzoini (tincture of benzoin). 

Tinctura Benzoini Composita (compound tincture of 
benzoin). 

Tinctura Cannabis Indicae (tincture of Indian cannabis). 

Tinctura Cantharidis (tincture of cantharides). 

Tinctura Cimicifugae (tincture of cimicifuga). 

Tinctura Guaiaci (tincture of guaiac). 

Tinctura Iodi (tincture of iodin). 

Tinctura Physostigmatis (tincture of physostigma). 

Tinctura Veratri (tincture of veratrum, tincture of veratrum 
viride). 

Fluid Extracts (fluidextracta) are liquid preparations 
(alcoholic or hydro-alcoholic) of organic drugs, so made that 
one cubic centimeter represents the active properties of one 
gram of the crude drug. The most important fluid extracts 
are: 

Fluidextractum Belladonnae Radicis (fluid extract of bella- 
donna root). 

Fluidextractum Buchu (fluid extract of buchu). 

Fluidextractum Cannabis Indicae (fluid extract of cannabis 
indica). 

Fluidextractum Cimicifugae (fluid extract of cimicifuga). 

Fluidextractum Cinchonae (fluid extract of cinchona). 

Fluidextractum Cocae (fluid extract of coca). 

Fluidextractum Conii (fluid extract of conium). 

Fluidextractum Ergotae (fluid extract of ergot). 



24 GENERAL CONSIDERATIONS. 

Fluidextractum Gelsemii (fluid extract of gelsemium). 

Fluidextractum Glycyrrhizae (fluid extract of glycyrrhiza). 

Fluidextractum Hydrastis (fluid extract of Hydrastis). 

Fluidextractum Hyoscyami (fluid extract of hyoscyamus). 

Fluidextractum Nucis Vomicae (fluid extract of nux 
vomica). 

Fluidextractum Pilocarpi (fluid extract of pilocarpus). 

Fluidextractum Rhamni Purshianae (fluid extract of cascara 
sagrada). 

Fluidextractum Rhois Glabra (fluid extract of rhus glabra). 

Fluidextractum Sarsaparillae (fluid extract of sarsaparilla). 

Fluidextractum Sarsaparillae Compositum (compound fluid 
extract of sarsaparilla). 

Fluidextractum Sennae (fluid extract of senna). 

Fluidextractum Spigelian (fluid extract of spigelia). 

Fluidextractum Uvae Ursi (fluid extract of uva ursi). 

Fluidextractum Veratri (fluid extract of veratrum, fluid ex- 
tract of veratrum viride). 

Fluidextractum Viburni Opuli (fluid extract of viburnum 
opulus). 

Fluidextractum Viburni Prunifolii (fluid extract of viburni 
prunifolium). 

Wines (vina) are alcoholic liquids made by fermenting the 
juice of fresh grapes. Medicated wi?ies are alcoholic prepara- 
tions in which white wine is used as a menstruum. The offi- 
cial wines are : 

Vinum Album (white wine). 

Vinum Antimonii (wine of antimony). 

Vinum Cocae (wine of coca). 

Vinum Colchici Seminis (wine of colchicum seed). 

Vinum Ergotae (wine of ergot). 

Vinum Ferri (wine of iron, wine of ferric citrate). 

Vinum Ferri Amarum (bitter wine of iron). 

Vinum Ipecacuanhas (wine of ipecac). 

Vinum Opii (wine of opium). 

Vinum Rubrum (red wine). 

Emulsions (emulsa) are aqueous preparations in which, 
by the aid of some mucilaginous material, insoluble, oily, or 
resinous substances are suspended in the form of minute 
particles or globules. The chief excipients used for making 
emulsions are acacia, tragacanth, and yelk of egg. Alcoholic 
preparations in large quantity are incompatible with emulsions, 
since they precipitate the excipient, the gum, or egg. The 
official emulsions are : 



PREPARATIONS OF DRUGS. 2$ 

Emulsum Amygdalae (emulsion of almond). 

Emulsum Asafcetidae (emulsion of asafetida). 

Emulsum Chloroformi (emulsion of chloroform). 

Emulsum Olei Morrhuae (emulsion of cod-liver oil). 

Emulsum Olei Morrhuse cum Hypophosphitibus (emulsion 
of cod-liver oil with hypophosphites). 

Emulsum Olei Terebinthinae (emulsion of oil of turpen- 
tine). 

Honeys (mellita) are Hquid preparations in which honey is 
used as a menstruum. The official honeys are : 

Mel (honey). 

Mel Despumatum (clarified honey). 

Mel Rosae (honey of rose). 

I/iniments (linimenta) are liquid preparations containing 
oleaginous substances, and intended for external application. 
With the exception of belladonna liniment and lime liniment, 
which are used as sedative applications, all the official lini- 
ments are of a stimulating character, and are to be applied 
with friction. The official liniments are : 

Linimentum Ammoniac (ammonia liniment). 

Linimentum Belladonnae (belladonna liniment). 

Linimentum Calcis (lime liniment, carron oil). 

Linimentum Camphorse (camphor liniment). 

Linimentum Chloroformi (chloroform liniment). 

Linimentum Saponis (soap liniment). 

Linimentum Saponis Mollis (liniment of soft soap, tincture 
of green soap). 

Linimentum Terebinthinae (turpentine liniment). 

I/Otions (lotiones) are weak medicated solutions or mix- 
tures for external use. When intended for the eyes, they are 
known as collyria. Collyria are usually applied by means of 
a pipet with a rubber bulb. There are no official lotions, but 
the following are in common use : 

Lotio Plumbi et Opii (lead-water and laudanum : lead 
acetate, 120 gr. (8.0 gm.); tincture of opium, \ fl. oz. (15 
c.c.) ; water, 16 fl. oz. (475 c.c.)). 

Lotio Hydrargyri Flava (yellow wash : corrosive sublimate, 
24 gr. (1.5 gm.); lime-water, 16 fl. oz. (475 c.c.)). 

Lotio Hydrargyri Nigra (black wash : calomel, 64 gr. (4.0 
gm.) ; lime-water, 16 fl. oz. (475 c.c.)). 

Collodions (collodia) are liquid preparations having for a 
menstruum a solution of pyroxylin (gun-cotton) in ether and 
alcohol. They are used externally, and are applied by means 
of a brush. With the exception of cantharidal collodion, 
which is used for blistering the skin, they are chiefly employed 
as protectants. The official collodia are : 



26 GENERAL CONSIDERATIONS. 

Collodium (collodion). 

Collodium Canthari datum (cantharidal collodion, blistering 
collodion). 

Collodium Flexile (flexile collodion). 

Collodium Stypticum (styptic collodion). 

Glycerites (glycerita) are solutions of drugs in glycerin. 
The following are official : 

Glyceritum Acidi Tannici (glycerite of tannic acid). 

Glyceritum Amyli (glycerite of starch). 

Glyceritum Boroglycerini (glycerite of boroglycerin). 

Glyceritum Ferri, Quininae et Strychninae Phosphatum (glyc- 
erite of the phosphates of iron, quinin, and strychnin). 

Glyceritum Hydrastis (glycerite of hydrastis). 

Glyceritum Phenolis (glycerite of phenol, glycerite of car- 
bolic acid). 

Enemas or Clysters (enemata) are liquid preparations 
intended for injection into the rectum. There are no official 
enemas. 

Extracts (extracta) are solid or semisolid preparations 
made by evaporating solutions of vegetable drugs. The 
menstrua are alcohol, diluted alcohol, water, water and 
ammonia-water, diluted acetic acid, or acetic acid and diluted 
alcohol. Being concentrated and solid or semisolid, they are 
well adapted for administering in the form of pills. The most 
important extracts are : 

Extractum Aloes (extract of aloes). 

Extractum Belladonnas Foliorum (extract of belladonna 
leaves). 

Extractum Cannabis Indicae (extract of cannabis indica). 

Extractum Cimicifugae (extract of cimicifuga). 

Extractum Colchici Cormi (extract of colchicum corm). 

Extractum Colocynthidis (extract of colocynth). 

Extractum Colocynthidis Compositum (compound extract 
of colocynth). 

Extractum Digitalis (extract of digitalis). 

Extractum Ergotae (extract of ergot). 

Extractum Euonymi (extract of euonymus). 

Extractum Gentianae (extract of gentian). 

Extractum Glycyrrhizae (extract of glycyrrhiza). 

Extractum Glycyrrhizae Purum (pure extract of glycyr- 
rhiza). 

Extractum Haematoxyli (extract of hematoxylon). 

Extractum Hyoscyami (extract of hyoscyamus). 

Extractum Jalapae (extract of jalap). 

Extractum Malti (extract of malt). 



PREPARATIONS OF DRUGS, 2J 

Extractum Nucis Vomicae (extract of nux vomica). 

Extractum Opii (extract of opium). 

Extractum Physostigmatis (extract of physostigma). 

Extractum Quassiae (extract of quassia). 

Extractum Rhamni Purshianae (extract of cascara sagrada). 

Extractum Rhei (extract of rhubarb). 

Extractum Stramonii (extract of stramonium). 

Extractum Sumbul (extract of sumbul). 

Extractum Uvae Ursi (extract of uva ursi). 

Masses (massae) are soft-solid preparations preserved in 
bulk and intended for forming into pills. The official masses 
are : 

Massa Ferri Carbonatis (mass of ferrous carbonate, Vallet's 
mass). 

Massa Hydrargyri (mass of mercury, blue mass, blue pill). 

Pills (pilulae) are small rounded^ masses containing one or 
more medicinal substances held together by some adhesive 
material, known as an excipient. The usual excipients are 
water, glycerin, tragacanth, acacia, honey, bread-crumbs, soap, 
confection of rose, extract of glycyrrhiza, and extract of gen- 
tian. Ordinarily, pills should not exceed in weight 5 grains, 
unless made of very heavy drugs of small bulk. The official 
pills are : 

Pilulae Aloes (pills of aloes). 

Pilulae Aloes et Ferri (pills of aloes and iron). 

Pilulae Aloes et Mastiches (pills of aloes and mastich). 

Pilulae Aloes et Myrrhae (pills of aloes and myrrh). 

Pilulae Asafcetidae (pills of asafetida). 

Pilulae Catharticae Compositae (compound cathartic pills). 

Pilulae Cartharticae Vegetabiles (vegetable cathartic pills). 

Pilulae Ferri Carbonatis (pills of carbonate of iron*; Blaud's 
pills). 

Pilulae Ferri Iodidi (pills of ferrous iodid). 

Pilulae Laxativae Compositae (compound laxative pills). 

Pilulae Opii (pills of opium). 

Pilulae Phosphori (pills of phosphorus). 

Pilulae Podophylli Belladonnae et Capsici (pills of podo- 
phyllum, belladonna, and capsicum). 

Pilulae Rhei Compositae (compound pills of rhubarb). 

Confections (confectiones) are soft masses made by mixing 
drugs with sugar and water or honey. Only two are official : 

Confectio Rosae (confection of rose). 

Confectio Sennae (confection of senna). 

Powders (pulveres) are drugs in the form of fine, loose, 
uncompacted particles. They are commonly dispensed in 



28 GENERAL CONSIDERATIONS. 

small paper packages, known as chartulce. But the latter are 
not suitable for highly volatile, hygroscopic, efflorescent, or 
deliquescent substances, or drugs with a disagreeable taste. 
When not suitable for papers, powders may be dispensed in 
capsules or cachets. Capsules are small gelatin cases or envel- 
opes (hard or soft) in which liquid or solid medicines are 
enclosed to be swallowed. Cachets are round concave wafers 
made of flour and water. The drug is contained in the cavity 
formed by bringing together the concave surfaces of two 
wafers. Their edges are fastened by being moistened and 
then pressed together. They are well adapted for enclosing 
powders having a disagreeable taste. They should be taken 
floated on a small quantity of water. 

Triturates (triturationes) are fine powders of medicinal 
substances intimately mixed with sugar of milk. There is 
only one official triturate : 

Trituratio Elaterini (triturate of elaterin). 

Tablets (tabellae) are small disks containing medicinal sub- 
stances mixed with sugar, and pressed into shape by metallic 
moulds. They are a convenient form in which to administer 
concentrated remedies, such as calomel, morphin, and strych- 
nin. There are no official tablets. 

Troches or lozenges (trochisci) are small, cylindrical or 
flat, solid masses, containing medicinal agents mixed with sugar 
and mucilage. Most of them are intended to influence the 
mucous membrane of the throat. The official troches are : 

Trochisci Acidi Tannici (troches of tannic acid). 

Trochisci Ammonii Chloridi (troches of ammonium chlorid). 

Trochisci Cubebae (troches of cubeb). 

Trochisci Gambir (troches of gambir). 

Trochisci Glycyrrhizae et Opii (troches of glycyrrhiza and 
opium). 

Trochisci Krameriae (troches of krameria). 

Trochisci Potassii Chloratis (troches of potassium chlorate). 

Trochisci Santonini (troches of santonin). 

Trochisci Sodii Bicarbonatis (troches of sodium bicarbonate). 

Suppositories (suppositoria) are solid bodies, of various 
shapes, intended to be inserted into the rectum, vagina, urethra, 
or nostril. The usual base is oil of theobroma. They are 
poured while in liquid form into suitable moulds and are so- 
lidified by cooling on ice. The only official suppositories are : 

Suppositoria Glycerini (suppositories of glycerin). 

Ointments (unguenta) are soft fatty preparations, melting 
at the temperature of the body, and containing medicinal sub- 
stances incorporated with a base of lard, a fixed oil, petrolatum, 
wax, or spermaceti. The official ointments are : 



PREPARATIONS OF DRUGS. 29 

Unguentum Acidi Borici (ointment of boric acid). 

Unguentum Acidi Tannici (ointment of tannic acid). 

Unguentum Aquas Rosae (ointment of rose-water, cold 
cream). 

Unguentum Belladonnas (belladonna ointment). 

Unguentum Chrysarobini (chrysarobin ointment). 

Unguentum Diachylon (diachylon ointment). 

Unguentum Gallae (nutgall ointment). 

Unguentum Hydrargyri (mercurial ointment). 

Unguentum Hydrargyri Ammoniati (ointment of ammoni- 
ated mercury). 

Unguentum Hydrargyri Dilutum (blue ointment). 

Unguentum Hydrargyri Nitratis (ointment of mercuric 
nitrate, citrine ointment). 

Unguentum Hydrargyri Oxidi Flavi (ointment of yellow 
mercuric oxid). 

Unguentum Hydrargyri Oxidi Rubri (ointment of red mer- 
curic oxid). 

Unguentum Iodi (iodin ointment). 

Unguentum Iodoformi (iodoform ointment). 

Unguentum Phenolis (ointment of phenol, ointment of car- 
bolic acid). 

Unguentum Picis Liquidae (tar ointment). 

Unguentum Potassii Iodidi (ointment of potassium iodid). 

Unguentum Stramonii (stramonium ointment). 

Unguentum Sulphuris (sulphur ointment). 

Unguentum Veratrinae (veratrin ointment). 

Unguentum Zinci Oxidi (ointment of zinc oxid). 

Unguentum Zinci Stearatis (ointment of zinc stearate). 

Oleates (oleata) are solutions of metallic oxids or alkaloids 
in oleic acid. There are five official oleates : 

Oleatum Atropinae (oleate of atropin). 

Oleatum Cocainae (oleate of cocain). 

Oleatum Hydrargyri (oleate of mercury). 

Oleatum Quininae (oleate of quinin). 

Oleatum Veratrinae (oleate of veratrin). 

Cerates (cerata) are solid fatty preparations resembling 
ointments, but made firmer by the addition of wax. They are 
of such consistence that they soften but do not melt at the 
body-temperature. The official cerates are : 

Ceratum (cerate). 

Ceratum Camphorae (camphor cerate). 

Ceratum Cantharidis (cantharides cerate). 

Ceratum Plumbi Subacetatis (cerate of lead subacetate, 
Goulard's cerate). 



30 GENERAL CONSIDERATIONS. 

Ceratum Resinse (rosin cerate, basilicon ointment). 

Ceratum Resinae Compositum (compound rosin cerate). 

Plasters (emplastra) are solids having a fatty or resinous 
base, and of such consistence that they do not melt but 
become adhesive when applied to the surface of the body. 
The official plasters are : 

Emplastrum Adhaesivum (adhesive plaster). 

Emplastrum Belladonnae (belladonna plaster). 

Emplastrum Capsici (capsicum plaster). 

Emplastrum Hydrargyri (mercurial plaster). 

Emplastrum Opii (opium plaster). 

Emplastrum Plumbi (lead plaster, diachylon plaster). 

Emplastrum Saponis (soap plaster). 

Papers (chartae) are strips of paper impregnated or coated 
with some medicinal substances. They are intended to be 
moistened and applied as a plaster, or else to be burned and 
the fumes inhaled. One paper is official : 

Charta Sinapis (mustard paper). 

Poultices (cataplasmata) are soft semiliquid preparations 
made of some cohesive substance, mixed with water, to be 
used for applying heat and moisture to the tissues, or for 
securing a local stimulant effect. They are usually made of 
flaxseed meal, slippery elm, or bread and milk. Charcoal 
may be added as an absorbent, mustard as a stimulant, and 
laudanum as an anodyne. Only one cataplasm is official : 

Cataplasma kaolini (cataplasm of kaolin). 

INCOMPATIBILITY IN PRESCRIPTIONS- 1 

Incompatibility in a prescription has been defined as that 
condition in which there exists either " a chemical decomposi- 
tion, a pharmaceutic dissociation, or a therapeutic opposition " 
of its constituents. The term is thus susceptible of three 
meanings. A prescription is chemically incompatible where 
chemical change results ; it is pharmaceutical^ incompatible 
where there is violation of correct pharmaceutic procedure; 
and there is therapeutic incompatibility where there is antago- 
nism in physiologic action. Now, accepting these definitions, 
a prescription may be chemically incompatible, and yet be just 
what the physician wants. It may be pharmaceutical^ incom- 
patible, and yet be desirable for the same reason. But it is 
never desirable when a change of chemical composition or 

1 This article has been written by Joseph W. England, Ph.G. 



INCOMPATIBILITY IN PRESCRIPTIONS. 3 1 

pharmaceutic character results in the formation of new prod- 
ucts having totally different therapeutic effects than those 
obviously intended. And this view — the intended therapeutic 
action of the prescription — the pharmacist should ever bear 
in mind. 

Every new prescription is largely a law unto itself until tried. 
Expertness in pharmaceutic manipulation, of which prescription- 
work is the highest type, is a matter of individual ability, which 
can be acquired only in the largest and best measures by per- 
sonal experience. The subject of incompatibility is not a for- 
midable one if there primarily exists a clear knowledge of the 
chemical or pharmaceutic properties of the substances used, so 
that any deviation from the right standard may be detected ; but 
here is the puzzling question, How are we to know but that, in 
the event of some chemical or pharmaceutic change, the phys- 
ician does not mean just such a change, and nothing else ? 

At first glance it seems strange, but there are some most 
successful physicians who, every now and then, write pharma- 
ceutically and chemically, the most incompatible prescriptions. 
Yet they have success ; and their happy results can only be 
due to the certain formation of new products or an alteration 
in pharmaceutic character of old ones. It does not follow 
that all prescriptions thus written are of the highest thera- 
peutic value. Far from it. The tendency of the times is 
steadily in the direction of greater simplicity in prescription- 
writing. 

It is to be regretted that the physician often depends in 
large measure upon the pharmacist for detecting any chemical 
or pharmaceutic incompatibility, and that the pharmacist 
depends solely and alone upon the physician for recognizing 
any therapeutic incompatibility. A physician, with his many 
duties, cannot be expected to have at his command the vast 
detail of pharmaceutic facts, nor can the pharmacist be con- 
sidered negligent in not possessing an extended acquaintance 
with the application of drugs in medicine; but it is clear that 
some elementary knowledge as to how drugs act and for what 
purposes they may be employed would be of great practical 
value to the pharmacist in affording him a clear idea of the 
therapeutic intent of the prescriber, and the ability to detect 
any deviation through a chemical or pharmaceutic error. An 
argument for therapeutic knowledge is not a step in the direc- 
tion of counter-prescribing. It is only a plea for broader edu- 
cation — for elementary therapeutics on distinctly pharmaceutic 
lines. With therapeutics pure and simple the pharmacist has 
nothing whatever to do. That is solely the province of the 



32 GENERAL CONSIDERATIONS. 

physician. Medicine and pharmacy are making rapid scien- 
tific progress — not in the same way, but upon certain definite 
lines of work and study, yearly becoming more distinct and 
widely separated, rendering each the more dependent on the 
other. 

To render a knowledge of the solubilities and insolubilities 
of inorganic compounds readily accessible, the following table 
is presented, based almost wholly upon Professor Attfield's 
"Statement of the Solubilities and Insolubilities of Salts," 
which expresses, directly or by inference, nearly five hundred 
soluble and insoluble compounds of the following inorganic 
basylous radicals : aluminum, ammonium, antimony, barium, 
bismuth, cadmium, calcium, chromium, cobalt, copper, ferric, 
ferrous, gold, lead, lithium, magnesium, manganese, mercuric, 
mercurous, nickel, potassium, silver, sodium, stannic, stannous, 
strontium, and zinc. 

In using this table it is only needful to remember the well- 
known chemical law that when a solution of a compound is 
brought in contact with a solution of another compound, and, 
by an interchange of radicals, an insoluble compound is ren- 
dered possible, that compound will be precipitated. 

Acetates are soluble. 

Arsenates are insoluble, except those of the alkali metals. 

Arsenites are insoluble, except those of the alkali metals. 

Bromids are soluble, except mercurous and silver ; those of 
antimony and bismuth are decomposed by water to form 
oxysalts. 

Carbonates are insoluble, except those of the alkali metals. 

Chlorids are soluble, except those of lead (s), 1 mercurous, 
and silver. 

Citrates are soluble, except those of manganese, mercurous, 
silver, and strontium, aluminum (s), barium (s), bismuth (s), 
cadmium (s), calcium (s), lead (s), zinc (s). 

Cyanids are insoluble, except the mercuric and those of the 
alkaline metals and earths. 

Hydrates are insoluble, except those of barium, strontium, 
calcium (s) f lead (s), and the alkali metals. 

Iodids are soluble, except those of antimony, bismuth, gold, 
lead (s), mercuric, mercurous, platinum (s), and silver. 

Nitrates are soluble. 

Oxalates are insoluble, except those of antimony (Y), chro- 
mium, ferric (s), ferrous (s), stannic, and the alka'i metals. 

' Oxids are insoluble, except those of barium, strontium, cal- 
cium (s), and the alkaline metals. 

1 (s) means sparingly soluble. 



INCOMPATIBILITY IN PRESCRIPTIONS. 33 

Phosphates (ortho) are insoluble, except those of the alkali 
metals. 

Sulphates are soluble, except those of barium, strontium, 
calcium (s), antimony, lead, mercurous (s), and silver (s). 

Sulphids are insoluble, except those of barium, calcium (s), 
strontium, and the alkali metals. 

Sulphites are soluble, except those of aluminum, antimony, 
barium, bismuth, calcium (s), cobalt (s), copper, ferrous (s), 
lead, manganese (s), nickel (s), silver, stannous, strontium, and 
zinc (s). 

Tartrates are soluble, except those of antimony, barium, bis- 
muth, cadmium (s), calcium (j), copper (s) t ferrous (s), lead, 
manganese (s), mercuric, mercurous, nickel (s), silver, stron- 
tium (s) f and zinc (s). 

Acids decompose hydrates, carbonates, and acid carbonates 
to form salts ; the stronger acids, which are largely inorganic, 
set free the weaker acids, which are largely organic ; or, brought 
in contact with alcohol or alcoholic solutions, form ethers ; 
alkaline hydrates, carbonates, and acid carbonates neutralize 
free acids, decompose some glucosids, and precipitate all alka- 
loids, some of which precipitates are soluble in excess of the 
precipitant, or in alcohol, if that liquid be present in sufficient 
amount to dissolve them. 

Oxidizing agents, such as nitric, hydrochloric, nitrohydro- 
chloric, picric, and chromic acids, and potassium bichromate 
and permanganate, with readily oxidizable substances, such as 
carbohydrates, alcohols, ethers, sulphur, phosphorus, sulphids, 
and organic matter in general, form explosive compounds. 
Potassium permanganate, if ordered in pill form, can best be 
made with cacao butter and cosmolin in very small quantity, 
and enclosed in gelatin capsules. Silver nitrate is reduced by 
organic matter to oxid, with the exception, it is said, of opium 
and extract of hyoscyamus. A very good way of making 
pills of it is with cacao butter and cosmolin, etc., as mentioned 
above under potassium permanganate ; syrup of ferrous iodid 
and potassium chlorate form a poisonous compound, and 
potassium iodid and potassium chlorate form a mixture which 
yields the poisonous iodate on being taken internally. 1 

Iodin and iodids yield precipitates with the alkaloids; bro- 
mids precipitate morphin and strychnin salts on standing, but 
a few drops of dilute hydrochloric acid added, after the addi- 
tion of the alkaloid, prevents the change. Sodium biborate 
precipitates morphin and cocain salts, but on the addition of a 
small quantity of boric acid, or with boric acid alone, precipi- 

1 Am. Jour. Phar., p. 277, 1876. 



34 GENERAL CONSIDERATIONS. 

tation does not take place. Mercuric chlorid with acidulated 
solutions of the alkaloids forms crystalline double salts ; potas- 
sium-mercuric iodid precipitates alkaloidal solutions. Solu- 
tions of quinin salts with those of the alkaline acetates, or 
with Basham's mixture, precipitate the sparingly soluble qui- 
nin acetate. Morphin solutions give the phenol reaction if 
mixed with tincture of ferric chlorid. 

Glucosids are decomposed by free acids and precipitated by 
tannin ; tannic and gallic acids precipitate alkaloids, albumin, 
gelatin, and the majority of metallic salts, and yield inks with 
iron solutions. 

Resinous tinctures and fluid extracts prescribed with aque- 
ous solutions should always be emulsified with acacia ; tinct- 
ures and fluid extracts made of stronger alcohol, mixed with 
those made of diluted alcohol, become turbid and precipitate, 
since the special solvent power of alcohol or of water for a 
substance diminishes in proportion to the quantity of the other 
liquid present. A " shake " label should always be used. 

When for internal use, fixed and volatile oils and oleoresins 
and aqueous solutions should always be emulsified, whether 
ordered or not, and to better emulsify the volatile oils they 
should have mixed with them, prior to emulsification, an equal 
volume of olive, almond, or cotton-seed oil. 

Tincture of ferric chlorid gelatinizes mucilage of acacia; 
free acids separate insoluble carminic acids from compound 
tincture of cardamom ; free acids precipitate glycyrrhizin from 
fluid extract of licorice. 

Commercial spirit of nitrous ether liberates iodin from solu- 
tions of iodids, decomposes antipyrin solutions to form a green 
nitroderivative, and precipitates mucilage of acacia, but if it be 
well diluted with water it can usually be added last without 
precipitating. Tincture of guaiac and spirit of nitrous ether 
are stated to be pharmaceutically incompatible by Potter, 
although they are often prescribed together ; likewise infusion 
of wild cherry with compound infusion of gentian, infusion of 
cinchona with compound infusion of gentian, and infusions 
with metallic salts generally. 

Sodium salicylate in solution precipitates the sparingly 
soluble salicylic acid if mixed with acids, and yields, if dis- 
pensed in powders with potassium acetate, the very deliques- 
cent potassium salicylate. Sodium salicylate in strong solu- 
tion is decomposed by tincture of ferric chlorid, but if well 
diluted first changes only into ferric salicylate. Sodium- 
benzoate solution is decomposed by acids to yield the spar- 
ingly soluble benzoic acid. 



METHODS OF ADMINISTERING DRUGS. 35 

Mercuric chlorid is decomposed by solution of potassium 
arsenite, but if the alkaline solution has first added to it, in 
slight excess, diluted hydrochloric acid, no precipitation will 
take place on the addition of the mercurial salt. Pyrophos- 
phate and phosphate of iron solutions precipitate with dilute 
phosphoric acid. The National Formulary recommends the 
usage of dilute metaphosphoric acid in place of the official 
" ortho" variety, as yielding a permanently clear solution. 

In conclusion, the writer would say that in this brief article 
he has endeavored to present, not an exhaustive list of special 
incompatibles, but simply a general expression of those liable 
to occur in the every-day routine of prescription-work. 

METHODS OF ADMINISTERING DRUGS* 

By the Mouth. — This is the most common method. 
Drugs may be administered by the mouth for their local 
action on the mouth, throat, stomach, or intestines, or for the 
purpose of being absorbed. When it is desired to influence 
the mouth or throat, the remedy is generally given in the 
form of a lozenge, and the patient advised not to take food or 
water for at least an hour afterward. Remedies intended to 
act directly on the mucous membrane of the stomach should 
be given when the stomach is empty, that is, half an hour or 
an hour before meals. Drugs intended to exert a direct 
influence on the intestine should be given two or three hours 
after meals, and preferably in firm pills. Sometimes such pills 
are coated with a substance, like keratin, that will resist the 
action of the gastric juice. 

Absorption may take place from any part of the alimentary 
canal. Powerful remedies, as nitroglycerin and tincture of 
aconite, are readily absorbed from the tongue. Absorption 
from the stomach is effected most quickly, as a rule, when the 
drug is given in solution on an empty stomach. However, 
in the case of remedies that have a local irritant action, it is 
far better to give them immediately after meals, so that by 
becoming mixed with the food their local effect is more or 
less avoided. 

A few remedies, such as calomel and salol, are digested 
almost entirely in the intestine. 

Hypodermic Method. — This consists in injecting medici- 
nal solutions into the subcutaneous tissue by means of the 
hypodermic needle and syringe. The advantages of this 
method are the great rapidity with which absorption is 
effected, and the certainty of securing the action of the entire 



$6 GENERAL CONSIDERATIONS. 

dose, since partial destruction of the remedy by the digestive 
organs is avoided. The disadvantages of this method are 
the pain inflicted, the liability of causing abscess, and the 
risk of throwing the solution directly into a vein. The 
alkaloidal salts, on account of their small bulk, are especially 
adapted for hypodermic use. Some remedies, such as toxins 
and antitoxins, are effective only when administered subcu- 
taneously. The best places to select for the injections are 
the extensor surface of the arm, the calf of the leg, the abdom- 
inal wall, and the buttock. Both the needle and the solution 
should be sterile. All the air should be expelled from the 
syringe before the injection is given, and great care should be 
exercised to avoid entering a vein. The dose of a drug 
administered hypodermically is ordinarily about one-half of 
that given by the mouth. 

Intravenous Injection. — This method is employed only 
in great emergency. Saline solution may be given intraven- 
ously in copious hemorrhage, uremia, diabetic coma, and in 
the algid stage of cholera. In the collapse of acute poison- 
ing, diffusible stimulants — ammonia-water, ether, whiskey — 
may be introduced into the system through the veins. 

By the Rectum. — Absorption through the rectum is not 
effected near so rapidly as through the stomach. To accom- 
plish the same result it is generally necessary to give twice 
the dose by the rectum that would be required by the mouth. 
This method is convenient when the stomach is unretentive. 
It also affords a means of acting directly on the bowel with 
drugs, and of removing hardened feces, flatus, and parasites. 
When the enema is to be retained in the bowel for its local 
effect, the fluid should be warm, the quantity should not 
exceed two ounces, and the injection should be made very 
slowly. When the enema is intended to bring about defeca- 
tion, one or two pints of fluid may be employed. When 
flatus is to be removed, an enema consisting of from 4 to 
6 ounces of the emulsion of asafetida is effective. Both 
local and constitutional effects may also be secured by means 
of suppositories containing medicinal agents. 

Inunction. — Many medicinal substances, if dissolved in 
fats, are fairly well absorbed through the unbroken skin, espe- 
cially if friction be used in their application. When this 
method of administration is employed systematically to secure 
a constitutional effect, different surfaces should be selected 
each day. The best surfaces for inunction are those having a 
thin skin, such as the axillae, popliteal spaces, the groins, and 
the inner sides of the thighs. The drugs that are most fre- 



CIRCUMSTANCES MODIFYING THE EFFECT OF DRUGS. 37 

quently introduced by inunction are mercury and iodin. A 
convenient method of treating syphilis in infants is by smear- 
ing mercurial ointment on a flannel binder worn around the 
abdomen. 

Bndermic Method.— This method consists in raising a 
blister, removing the epidermis, and sprinkling on the raw 
derm the drug that is to be absorbed. It is very painful, and 
it is far less satisfactory than the hypodermic method. 

Flttnigation. — This method is sometimes employed in 
syphilis instead of inunction. A mercurial salt, preferably 
calomel, is volatized from a tin plate suspended over a spirit- 
lamp. The latter is placed under a cane-seated chair, upon 
which is seated the patient, disrobed and surrounded by a 
blanket fastened to the neck. 

Inhalation. — Volatile drugs are rapidly absorbed from 
the respiratory tract, and this method is especially employed 
for the administration of drugs which induce general anes- 
thesia, such as ether, chloroform, and nitrous oxid. The 
effect of other volatile substances, like amyl nitrite, is also 
secured by inhalation. Medicated vapors and sprays are 
employed to influence directly the mucous membrane of the 
respiratory tract. 

ORCUMSTANCES MODIFYING THE EFFECT OF 

DRUGS. 

The effect of drugs is modified by many circumstances, 
chief of which are the age of the patient, sex, race, body- 
weight, temperament, disease, temperature, habit, idiosyncrasy, 
method of administration, time of administration, preparation 
of the drug, and dose. 

Habit. — With many drugs continuous use induces tolera- 
tion. This is particularly true of opium. Increased elimina- 
tion and diminished absorption may play a part in the 
development of this condition, but it is probably due very 
largely to a change in the tissues themselves, whereby they 
are rendered less susceptible to the influence of the drug. 

Idiosyncrasy. — This is a peculiar susceptibility or insus- 
ceptibility of one or more of the tissues to the influence of 
certain drugs. Less than % of a grain of calomel has been 
known to induce salivation. The smallest dose of quinin will 
in some individuals cause a diffuse erythematous rash. 

Cumulative Action. — This is the property which some 
drugs have, after they have been given for a certain length of 
time, of producing a severe and more or less sudden effect. 



38 GENERAL CONSIDERATIONS. 

It is probably due in most instances to an accumulation of 
the drug in the tissues, excretion, for one reason or another, 
being less rapid than absorption. In some cases, however, it 
may depend upon irregular absorption, a large quantity of the 
drug suddenly entering the circulation from the alimentary 
canal, where, owing to some accidental condition, there has 
been an undue accumulation. 

DOSAGE. 

The circumstances which modify the effect of drugs must 
also necessarily influence dosage. The most important con- 
ditions to be considered are the age, sex, weight, and disease. 

Age. — Children require smaller doses than adults. Two 
rules are in common use for determining the proper dose for 
children of different ages : 

Young's rule is as follows : Add 1 2 to the age and divide 
by the age, and the quotient will be the denominator of a 
fraction the numerator of which is 1. Thus, for a child of 

four years, = 4, and the dose is j£ that for an adult. 

4 

Cowling's rule is to divide the age of the child at its next 
birthday by 24. Thus, for a child 3 years old, the dose 
would be -£% = •§■ of the adult dose. 

These rules, of course, are only approximately correct, and 
each drug must be considered by itself in reference to dose. 
Thus, children are very susceptible to opium, and, therefore, 
the dose of this drug must be smaller than the age would 
apparently indicate. On the other hand, arsenic and bella- 
donna are well borne by children, and, therefore, relatively 
larger doses of these drugs can be prescribed. 

Sex. — Women generally require smaller doses than men. 
The dose for a woman is about four-fifths of that for a man. 

Weight. — Weight has less influence on dosage than either 
age or sex, but a very heavy muscular individual will generally 
require a larger dose than one of slight frame. 



DRUGS 



CIRCULATORY STIMULANTS. 



Circulatory stimulants are drugs which increase the effi- 
ciency of the heart. They may increase the force of the beat 
and lessen its rate, or they may increase both the force and the 
rate of the beat. Among those which strengthen the heart- 
beat, but decrease its frequency, are the following : 

Digitalis. Squill. 

Strophanthus. Canadian hemp (apocynum). 

Convallaria. Adrenalin. 

Adonis vernalis. Strychnin. 

Among those which increase both the force and frequency 
of the beat may be mentioned the following : 

CafTein. Atropin. 

A number of drugs quicken the heart-beat and slightly in- 
crease the output of the heart per unit of time, not so much 
by acting on the heart directly as by causing peripheral irrita- 
tion and a reflex stimulation of the organ. The effect of these 
drugs on the circulation is necessarily transitory. The import- 
ant members of this group are : 

Ammonia. Ether. 

Alcohol. Camphor. 

Increase of Blood-pressure. — A drug may increase the 
blood-pressure (i) by stimulating the heart directly (digitalis, 
strophanthus, partly in this way) ; (2) by constricting the ves- 
sels directly (adrenalin) ; (3) by constricting the vessels through 
a central action (digitalis, strychnin, atropin). The blood- 

39 



40 CIRCULATORY STIMULANTS. 

pressure may also be increased by compression of the peripheral 
vessels, as in the pneumatic rubber suit devised by Crile ; and 
by increasing the amount of fluid in the vessels (salt solution 
intravenously or subcutaneously). 

Acceleration of the Heart-beat. — This can be brought 
about (i) by excitement or peripheral irritation (alcohol, ether) ; 
(2) by stimulation of the heart itself (caffein) ; (3) by direct de- 
pression of the inhibitory nerves, centrally or peripherally 
(belladonna) ; (4) by reduction of the blood-pressure and in- 
direct depression of the inhibitory centers in the medulla 
(nitrites, partly in this way) ; and (5) theoretically, by stimula- 
tion of the accelerator mechanism of the heart. 

Circulatory stimulants are indicated in heart-failure and vaso- 
motor paresis from various causes. In collapse, quickly acting 
stimulants, such as ammonia, alcohol, and camphor, are often 
effective, especially when their administration is combined with 
the external application of heat and the injection of salt solu- 
tion intravenously, subcutaneously, or into the rectum. In 
shock (exhaustion of the vasomotor centers) the same meas- 
ures also may be used, but they are not likely to prove so effi- 
cacious as intravenous injections of adrenalin, which directly 
constricts the peripheral vessels, and thus serves to increase 
the tonus in the medulla oblongata. 

Circulatory stimulants with a constricting effect upon the 
peripheral arteries, like digitalis, are often exceedingly useful 
in valvular disease of the heart with simple dilatation, especially 
when there is dropsy. For a certain degree of tension in the 
arteries it is necessary (1) to equalize the two circulations, (2) 
to keep the coronary arteries well filled and so secure for the 
heart-muscle the requisite amount of nourishment, (3) to pro- 
mote diuresis. When, however, the myocardium is the seat 
of advanced degenerative changes, drugs like digitalis must be 
used with considerable caution, since their constricting influence 
upon the vessels may be much more pronounced than their 
stimulating effect upon the heart. In such cases a vasodilator, 
as one of the nitrites, should also be given, or a heart stimulant 
selected that will cause less contraction of the muscular fibers 
of the vessels. Drugs with the digitalis action also act favorably 
in cases of cardiac incompetence by diminishing the number 
of the heart's contractions (prolonging the diastolic phase), 
and thus giving more rest to the crippled organ. 

In heart-weakness resulting from asthenic fevers, drugs of 
the digitalis group are generally less beneficial than alcohol, 
strychnin, and caffein. 



AMMONIA. 41 

AMMONIA. 

(NH,) 

Ammonia is a colorless gas having an intensely pungent 
odor and acrid taste, and obtained as a by-product in the 
manufacture of coal-gas. It acts as a base in uniting with 
acids to form salts. 

Preparations. Dose. 

Aqua Ammonias, U. S. P. (io per cent, of 

the gas) 10-30 min. (0.6-2.0 c.c). 

Aqua Ammoniae Fortior, U. S. P. (28 per 
cent, of the gas). 

Spiritus Ammoniae, U. S. P. (10 per cent, of 

the gas) 20-60 min. (1.0-4.0 c.c.) 

Spiritus Ammoniae Aromaticus, U. S. P. 
(ammonium carbonate, 34; ammonia- 
water, 90 ; aromatic oils ; water to 
make iooo parts) 20-60 min. (1.0-4.0 c.c). 

Linimentum Ammoniae, U. S. P. 

Physiologic Action. — Circulatory System. — Both the 
inhalation of ammonia and the administration of its preparations 
by the mouth produce a transient elevation of the blood-pres- 
sure. This effect is due not to the direct action of the drug on 
the heart, but to the reflex stimulation of the organ and also 
of vasomotor center in the medulla from irritation of the nasal 
or gastric mucous membrane. Sometimes temporary slowing 
of the pulse is observed as the result of reflex stimulation of 
the inhibitory center. Elevation of blood-pressure also occurs 
when ammonia is injected subcutaneously or intravenously if 
the dose be moderate, but in this case the vasomotor center is, 
probably, stimulated directly as well as reflexly. Very large 
doses of ammonia, administered intravenously, lower the blood- 
pressure by directly depressing the vasomotor center and the 
heart. 

Respiratory System. — Moderate doses increase the depth 
and volume of the respirations by stimulating reflexly the 
respiratory center in the medulla. This effect is especially 
pronounced when the drug is administered by inhalation. 

Alimentary Canal. — In the stomach, ammonia, like other 
alkalis, serves to neutralize any free acid that may be present, 
and in dilute solution is sufficiently stimulating to act as a 
carminative. 

Local Action. — Locally, it is a powerful irritant, though its 
action is not corrosive like that of the fixed alkalis. Even in 
concentrated solution it does not dissolve the epidermis, but 
passes through it and produces a blister. 



42 CIRCULATORY STIMULANTS. 

Elimination. — As ammonia undergoes rapid decomposition 
in the body, its action is very evanescent. Unlike the fixed 
alkalis, it does not add to the alkalinity of the urine, for after 
absorption it is transformed into urea, in which form it is 
excreted. 

Toxicology. — Ammonia-poisoning is characterized by 
severe burning pain in the fauces, esophagus, and stomach, 
dyspnea, persistent vomiting and purging, a rapid, thready 
pulse, and the symptoms of collapse. The mind may remain 
clear until the end, but coma often precedes death. The 
intense irritation of the throat sometimes causes edema of the 
larynx, in consequence of which death may result in a few 
minutes from asphyxia. 

Treatment. — The ammonia should be neutralized by the 
administration of some weak acid, such as vinegar. Subse- 
quently the inflammation should be allayed by demulcents 
and opium. Asphyxia from laryngeal edema will demand 
tracheotomy. 

Therapeutics. — Ammonia is employed chiefly as a quickly 
acting cardiac and respiratory stimulant, as an antacid in gas- 
tric acidity, and as a counter-irritant. 

In syncope, collapse, and other forms of sudden heart-failure, 
ammonia is an invaluable stimulant. In gastralgia and heart- 
burn dependent upon unnatural acidity of the stomach-con- 
tents, it is a useful antacid. As an antacid it is employed also 
externally to neutralize the poison in the bites of certain 
insects. As a rubefacient, ammonia liniment is a useful 
remedy in chilblains, chronic rheumatism, and myalgia. 

Administration. — The spirits of ammonia are usually 
selected for internal administration. They should be given 
well diluted. For subcutaneous or intravenous injection am- 
monia-water is the most suitable preparation. The latter is 
also used in various rubefacient liniments. Stronger ammonia- 
water, applied on a pledget of cotton, covered with a watch- 
crystal, has been used as a vesicant, but the process is very 
painful and the blister is slow in healing. 

Incompatibles. — Ammonia is incompatible with mineral 
and vegetable acids, chloral, and alkaloids. With solutions of 
corrosive sublimate it forms the insoluble ammoniated mer- 
cury. With solutions of ferric salts it forms the sesquioxid of 
iron, which is the antidote to arsenic. With tincture of iodin 
it yields a black precipitate of nitrogen iodid, which when dry 
is very explosive. With solutions of formaldehyd it forms 
uro tropin. 



ALCOHOL. 43 

AMMONII CARBONAS, U. S. P. 

(Ammonium Carbonate, NH 4 HC0 3 .NH 4 NH 2 C02.) 

Carbonate of ammonium occurs in the form of white, trans- 
lucent, crystalline masses having an extremely pungent odor 
and acrid taste. When exposed to the air it breaks up into a 
white powder — bicarbonate of ammonium. It is soluble in 4 
parts of water. Its dose is 5-10 gr. (0.3-0.6 gm.). 

Physiologic Action and Therapeutics.— Ammonium 
carbonate acts like ammonia, and is used for the same purpose, 
that is, to stimulate reflexly the medullary centers. It also 
shares with other ammonium compounds the property of ren- 
dering the bronchial secretion less viscid, hence it is frequently 
employed as an expectorant. It is particularly efficacious in 
acute pulmonary diseases associated with cardiac and respiratory 
weakness, such as severe bronchitis, bronchopneumonia, and 
croupous pneumonia. 

Administration. — To guard against excessive gastric irri- 
tation, it is usually prescribed in mucilage or syrup of acacia, 
as in the following formula : 

5k Ammonii carbonatis, sjij (8.0 gm.); 

Pulveris acacise et sacchari, aa q. s ; 

Tincturae lavandulse composite, f^ij (8.0 c.c); 

Aquae, q. s. ad f^iij (90.0 c.c). — M. 

Sig. A teaspoonful in water every two or three hours. 

Incompatibles. — The same as the preparations of am- 
monia. Ammonium carbonate cannot be prescribed with 
syrup of squill, syrup of citric acid, or syrup of ipecac, or other 
syrups of acid reaction. 

ALCOHOL, U. S. P. 

(Ethyl Alcohol, C 2 H 6 HO.) 

Ethyl alcohol is obtained from the distillation of fermented 
saccharine material. The official preparation contains 92.3 
per cent, by weight of absolute ethyl alcohol, and appears as 
a colorless, inflammable liquid, having a pungent odor and a 
burning taste. 

Preparations. 

Alcohol Absolutum, U. S. P. (99 per cent, alcohol). 
Alcohol Dilutum, U. S. P. (41.5 per cent, absolute alcohol). 
Spirits : 

Spiritus Frumenti, U. S. P., or whisky (37 to 47.5 per cent, alcohol), distilled 

from fermented grain. 
Spiritus Juniperi Compositus, U. S. P., equivalent to gin (about 60 per cent. 

alcohol). 
Spiritus Vini Gallici, U. S. P., or brandy (39 to 47 per cent, alcohol), distilled 

from fermented grapes. 



44 CIRCULATORY STIMULANTS. 

Malt Liquors : 

^ ' 1 obtained from the fermentation of malted grain, and contain from 3 to 

p C rt ' I ^ P 61 cent * alco ^°^ 

Wines : 
Vinum Album, U. S. P., or white wine (7 to 12 per cent, alcohol). 
Vinum Rubrum, U. S. P., or red wine (7 to 12 per cent, alcohol). 
Vinum Portense, or port wine (15 to 20 per cent, alcohol). 
Vinum Xericum, or sherry wine (15 to 20 per cent, alcohol). 
The official wines are made by fermenting the unmodified juice of the grape. 

Physiologic Action. — Circulatory System. — The exact 
action of alcohol on the circulation is still obscure. Moderate 
doses cause acceleration of the pulse and flushing of the sur- 
face, without materially augmenting the blood-pressure. The 
acceleration of the pulse is due (1) in part to mental and physi- 
cal excitement, (2) in part to reflex stimulation from gastric 
irritation, and probably also (3) in part to a direct action, slight 
and transitory, on the nervous or muscular mechanism of the 
heart itself. The flushing of the surface is caused by dilatation 
of the peripheral vessels from depression of the vasomotor 
centers. The vessels of the splanchnic area apparently do not 
share in the dilatation ; indeed, there is some reason for believing 
that they are slightly constricted. 

While alcohol increases the amount of blood pumped by the 
heart in a given length of time (Wood and Hoyt), it does not cause 
under ordinary conditions any material change in the blood- 
pressure, probably because the actions of the drug in increasing 
the heart power and in widening the peripheral vessels are 
about equally balanced. It is generally admitted, however, 
that very large amounts of alcohol produce a notable fall in the 
arterial pressure through depression of the vasoconstrictor 
centers and the heart muscle. 

Nervous System. — The first effect of alcohol upon the 
nervous system is one of apparent stimulation, with indications 
of increased mental and motor activity. As a matter of fact, 
however, attention, self-control, judgment, and the higher mental 
processes generally, as well as the capacity of the individual for 
physical work, are distinctly impaired at once by even small 
quantities of the drug, and, therefore, the vivacity of speech and 
excess of motor energy often displayed in the early stage of 
alcoholic intoxication must be attributed rather to a depression 
of the inhibitory or controlling functions than to a true stimu- 
lation of the higher cerebral centers. 

With a very large dose of alcohol the stage of excitement is 
soon followed by one of paralysis, which is characterized by 
loss of memory, thick speech, ataxia, lessened reflex irritability, 
and somnolence, gradually deepening into coma. 



ALCOHOL. 45 

Respiration. — Moderate amounts of alcohol slightly quicken 
the respiration and increase the amount of air inhaled. These 
effects are probably produced reflexly by irritation of the 
stomach, as there is no evidence to show that the drug is a 
direct respiratory stimulant. Failure of respiration is the usual 
cause of death in fatal alcoholic poisoning. 

Alimentary Canal. — Alcohol augments the flow of saliva 
and gastric juice, quickens peristaltic movements, and accele- 
rates absorption. Very small amounts (less than 2 per cent.) 
favor peptic digestion, while large amounts (more than 10 per 
cent.) distinctly retard it. Large doses of concentrated alcohol 
produce acute gastritis. 

Effect on Metabolism. — Moderate amounts of alcohol 
undergo combustion in the body, spare to a certain extent the 
oxidation of fats and proteids, supply energy to the tissues, 
and serve to maintain the body-weight, when, for any reason, 
the diet is insufficient. To this extent alcohol is a food. 

Temperature. — Alcohol lowers the body temperature to a 
slight extent by dilating the skin-vessels, and so allowing an 
undue loss of heat. Accompanying the fall of temperature a 
sensation of warmth is experienced, which is also due to the 
increased amount of blood in the skin. 

Elimination. — In moderate doses alcohol undergoes com- 
plete oxidation in the body, only a small amount (1 or 2 per 
cent.) being eliminated unchanged by the kidneys and lungs. 
The products of its decomposition are carbon dioxid and water. 

Local Action. — Concentrated solutions withdraw water 
from the cells and precipitate albumins, and thus produce 
decided irritation. When applied to skin in dilute form and 
allowed to evaporate, it abstracts heat and produces a sensation 
of coldness. 

Action on Lower Organisms. — Alcohol possesses moderate 
germicidal properties. According to the researches of Har- 
rington and others the best results are obtained with alcohol 
of 60 per cent, strength, its germicidal power diminishing with 
departures in both directions from this dilution. 

Toxicology. — The ingestion of large quantities of alcohol 
produces the following symptoms : Flushing of the face, men- 
tal excitement, quickening of the pulse and respiration ; then 
incoherent speech, delirium, dilated pupils, loss of co-ordina- 
tion, subnormal temperature, vomiting, and, finally, stupor and 
coma. Not infrequently the coma is interrupted by convul- 
sive seizures. In most cases, if the dose has not been too 
large, recovery follows in a day or two. 

Care must be taken to distinguish acute alcoholism from 



fti CIRCULATORY STIMULANTS. 

uremia, opium-rxMsoning, and apoplexy. The urinous odor 
of the breath, the accentuation of second aortic sound, the 
small pupils, and the presence of albumin in the urine will 
serve to distinguish uremia. The small pupils, slow respira- 
tion, and slow pulse will indicate opium-poisoning. The 
unequal pupils, hemiplegia, and elevated temperature will 
serve to separate apoplexy from alcoholism. 

Treatment. — The stomach should be emptied by the 
stomach-pump, a stimulating emetic, or the hypodermic in- 
jection of apomorphin (gr. ^ — 0.007 g 111 - - If th e pulse 
-:ens, stimulants like strychnin, ammonia, or digitalis 
should be administered hypodermically. 

Chronic alcoholism is characterized by disturbed sleep, 
fine tremors, mental impairment, injection of the eyes, redness 
of the nose, and the symptoms of gastro-intestmal catarrh. 
When the habit is long-continued, degenerative and cirrhotic 
changes in the heart, blood-vessels, liver, and kidneys are apt 
to develop. 

A common complication of chronic alcoholism is delirium, 
tremens, which is generally excited by temporary excess, an 
injury, or some acute intercurrent disease, especially pneu- 
monia. It is manifested by great mental excitement, insom- 
incoherent speech, tremors, disordered intellect, and terri- 
fying hallucinations of sight or hearing. The pulse is rapid 
and feeble, the appetite is lost, the bowels are constipated, and 
the temperature slightly elevated. In favorable cases con- 
valescence follows in a few days, but not infrequently typhoid 
symptoms develop and the attack ends in death. 

Among other sequels of dipsomania may be mentioned 
pneumonia, chronic meningitis, multiple neuritis, amblyopia, 
epilepsy, and dementia. 

Treatment of Delirium Tremens — As there has usually 
been a complete abstinence from food during the debauch 
leading to the delirium, nutritious foods are always necessary, 
and the best are milk with lime-water and highly seasoned 
beef-tea. Sleep must be secured by chloral (gr. xx — 1.3 gm.), 
hyoscin (gr. yl^ — .00065 gm.), potassium bromid (sj — 4-0 gm.), 
or paraldehyd (fsss-fej — 2.0-4.0 c.c). Sir William Broadbent 
has found cold affusions, followed by vigorous rubbing, of 
great service in promoting sleep. Active catharsis should be 
encouraged. When the pulse is weak, strychnin and digitalis 
will be found useful stimulants. Subcutaneous injections of 
normal salt solution are sometir effective. In many 

cases physical restraint will be required ; it may be secured by 
strapping the patient to the bed with sheets. Should profound 



DIGITALIS. 

stupor develop, the application of a blister to the back of the 
neck or a few light touches of the actual cautery will 
serve to arouse the patient. 

Therapeutics. — Alcohol is employed internally as a dif- 
fusible circulator}- stimulant, a _ ; t:machic, a food, and a 
chemical antidote. Externally it is used as an antiseptic a 
stimulant, a hemostatic, and an antihydrotic. 

In all forms of sudden heart-failure, as in syncope, shock, 
snake-bite, and acute febrile disease, alcohol is an invaluable 
stimulant In the continued fevers, lik -'..'.:", it fills a 

triple role : it serves as a food, as a general stimulant, and as 
a promoter of digestion. In these cases, however, it is well 
to withhold it until the pulse flags or the heart-sounds indi- 
cate a weakening of the circulation. Brunton's rule for 
administering alcohol is a good one: Sit by the si tie :: your 
patient for a while and watch him after the adrriiriistration of a 
dose of alcohol, and if you find that the alcohol brings back 
the various functions nearer to the normal, then it is doing 
good ; if the functions of the organs diverge further from the 
normal after the administration of alcohol, then it is doing 
harm." 

In chronic diseases, like phthisis, obstinate atari: sia. 

and valvular affections of the heart, it often does good, but it 
should be administered tentatively, with due regard for the 
danger of producing chronic alcoholism. 

The power which alcohol possesses of counteracting tfa : 
escharotic action of carbolic acid was first pointed out 
Phelps and Powell in 1 899. Since then sufficient evidence has 
accumulated to warrant die belief that alcohol, when admin- 
istered promptly, is a valuable antidote in carbolic-acid poison- 
ing. From 1 to 3 ounces of diluted alcohol should be poured 
into the stomach through a tube, and lavage immediately prac- 
tised with water containing a soluble sulphate 

External Uses. — Bathmg with send ad u 

to other measures in disinfecting the skin. A mixture of alcohol 
and water makes a useful evaporating lotion in the treatment 
of contusions with ecchymosis. Applied to wounded surfac es it 
is effective in controlling capil.t.r : zing. Sponging the body 
with alcohol and water is often s erw g the night- 

sv/eats ::" z '.:-.'::: ; : ; . 

DIGITALIS. U. S. P. 
(Faxglore.) 

Digitalis is the dried leaves of Digitalis biennial 

herb growing in Central and Southern Europe. It : tains 
several principles, all of which are probably of the 



48 CIRCULATORY STIMULANTS. 

glucosids, the most important being digitoxin, digitophyllin, 
digitalin, digit alein, digitonin, and digitin. The first four are 
cardiac stimulants and vasoconstrictors, and represent more or 
less imperfectly the virtues of the crude drug. Digitonin is a 
member of the saponin group and is not absorbed from the 
alimentary canal. By its presence, however, the other glu- 
cosids, which are insoluble in water, are held in suspension 
when an infusion is made of the leaves. Digitin is inert. 

Preparations. Dose. 

Tinctura Digitalis, U. S. P 5-20 min. (0.3-1.2 ex.). 

Fluidextractum Digitalis, U. S. P. . . . 1-2 min. (0.06-0. 12 c.c). 

Infusum Digitalis, U. S. P 1-4 fl. dr. (4.0-15.0 c.c). 

Extractum Digitalis, U. S. P i-igr. (0.010-1.016 gm.). 

Pulvis Digitalis |— 2 gr. (0.032-0.13 gm. ). 

Digitalin (an amorphous powder, ex- 
tremely variable in composition) - . . -50-jft gr. (0.001-0.002 gm.). 

Digitaline Cristallisee, or Nativelle's digi- 

taline (impure digitoxin) -zhnh S r - (0.00025-0.001 gm.). 

Digitalinum Germanicum (a mixture of 
glucosids, soluble in water and alcohol ; 

suitable for hypodermic use) .... -£$- ^ gr. (o.ooi-c.003 gm.). 

Physiologic Action. — Circulatory System. — The domi- 
nant action of digitalis is on the circulation. In tJierapentic 
doses it slows the pulse and raises the blood-pressure. The 
slowing of the pulse is due mainly to stimulation of the vagi 
(prolonged diastole), but partly to the action of the drug on the 
cardiac muscle (prolonged systole). The increased blood- 
pressure is due (1) to more complete and forcible contractions 
of the ventricle and (2) to constriction of the peripheral vessels. 
The vasoconstriction is mainly the result of the direct action 
of the drug on the muscle of the arterioles, but it is partly in- 
duced by stimulation of the vasomotor center. 

The action of digitalis on the vagi is antagonistic to its action 
on the cardiac muscle. The tendency of the inhibitory action is 
to cause disastolic slowing and less complete systole, while that 
of the muscular action is to cause more complete and pro- 
longed systolic contraction (systolic slowing) and less complete 
diastole. Nevertheless, the sum of these effects is an increase 
in the total output of the heart per unit of time ; for, although 
the slowing of the heart tends to decrease the output, the de- 
crease is more than compensated for by the increased amount 
of blood that enters the ventricle because of the longer diastole, 
and leaves it because of the stronger systole. 

In the first stage of the poisoning the pulse becomes slow and 
irregular, and the output of the heart per minute less than it 
was before the administration of the drug. This effect is to be 



DIGITALIS. 49 

ascribed to excessive inhibitory stimulation. In the second 
stage of poisoni?ig the pulse becomes rapid and still more 
irregular. The output of the heart per minute varies. For a 
time it may be increased in consequence of the greater number 
of ventricular contractions, but soon it falls off, owing to the 
imperfect relaxation of the ventricle. Finally, the heart passes 
in fibrillary contractions and stops in diastole. The phenomena 
of the second stage of poisoning by digitalis are to be ascribed 
to increased irritability of the heart muscle. 

It has been shown that decided hypertrophy of the heart 
can be induced in animals by giving them digitalis in small 
doses for a prolonged period. 

Local Action. — Digitalis is intensely irritant, and when 
applied to mucous membranes causes smarting, redness, and 
swelling. Of the glucosids, digitoxin is the most irritant and 
digitalin the least. 

Alimentary Canal. — Large doses of the drug frequently 
excite nausea, vomiting, and diarrhea. 

Nervous System. — The medulla appears to be the only part 
of the central nervous system influenced by digitalis. Even in 
therapeutic doses the drug stimulates the inhibitory cardiac 
and the vasoconstrictor centers. Toxic doses increase the 
depth and rate of the respirations and sometimes cause con- 
vulsions. It is possible that the vomiting, which follows the 
exhibition of large doses of the remedy, is partly of central 
origin. 

Kidneys. — In health digitalis has but little diuretic action, 
but when the urine is scanty from low arterial tension, it 
induces free diuresis. It may, therefore, be assumed that the 
drug has little or no direct influence on the renal epithelium, 
but that it indirectly increases the quantity of urine through its 
action on the heart and blood-vessels. The elimination of 
digitalis is effected very slowly. 

Toxicology. — Digitalis-poisoning is characterized by ob- 
stinate vomiting, diarrhea, headache, disordered vision, and a 
very slow full pulse. The pulse, however, often becomes sud- 
denly rapid and feeble when the patient sits up. Later, even 
in recumbency, the pulse becomes rapid, irregular, and thready, 
the urine scanty or suppressed, the surface cold, and the mind 
cloudy. Intelligence, however, is not lost until shortly before 
death. Occasionally convulsions develop during the last stage. 

The uninterrupted use of digitalis in full doses is sometimes 
followed by the sudden appearance of toxic symptoms ; this 
untoward effect seems to be due to the cumulative action of 
the drug, and is especially liable to occur when there is no 

4 



50 CIRCULATORY STIMULANTS. 

diuretic effect, and after the removal of serous effusions by 
paracentesis. In the first instance elimination is interfered 
with, and in the second, absorption is effected with undue 
rapidity. The earliest manifestations of this accident are 
usually irregularity of pulse, precordial distress, and the 
appearance of the heart-beats in couples, the first of which 
only can be detected at the wrist. When a prolonged use of 
the remedy is required, it should be suspended at intervals for 
a definite period, so as to allow of complete elimination. 

Treatment of Poisoning'. — The patient must be kept in the 
recumbent position. Emetics or purges may be necessary for 
the removal of any part of the poison that is still unabsorbed. 
Tannic acid should be administered as a chemical antidote. It 
is important to maintain the body-temperature by the applica- 
tion of external heat. Alcoholic stimulants may prove useful. 
Aconite has been recommended on theoretic grounds as a 
physiologic antidote, but it should be used with considerable 
caution. 

Therapeutics. — Digitalis fills three important offices : It 
serves as a powerful cardiac stimulant ; it slows the heart and 
regulates its rhythm, and it acts as a diuretic. 

As a Cardiac Stimulant. — Digitalis is especially indicated 
when there is simple dilatation of the heart. By prolonging 
diastole it rests the heart and allows the ventricles to become 
more completely filled; and by strengthening the systole it 
aids in the more thorough emptying of these chambers, this 
combined action tending to readjust the inequality in the 
arterial and venous circulations. Moreover, by forcing more 
blood into the coronary arteries, digitalis may permanently in- 
fluence for good the tone of the heart muscle. 

Hypodermic injections of digitalin are often useful in syncope, 
in collapse from various causes, and in poisoning by cardiac 
depressants. 

In chronic valvular disease with symptoms of failing compen- 
sation digitalis is often of the utmost value, but it must not be 
used indiscriminately. The chief indications for its use are 
dropsy, deficient urination, and a rapid, weak, and irregular 
pulse. When cardiac hypertrophy overbalances dilatation and 
the symptoms of arterial hyperemia exist, its administration 
will be productive of harm. 

The best results are seen in mitral regurgitation. In this 
disease digitalis secures a more perfect closure of the mitral 
valves by causing a more vigorous contraction of the muscles 
surrounding the orifice ; moreover, it supports the right ven- 
tricle, which is subjected to a severe strain on account of the 



DIGITALIS. 51 

increased resistance in the pulmonary circuit. In some cases 
of mitral regurgitation, digitalis, although apparently indi- 
cated, fails to afford relief because of the existence of peri- 
cardial adhesions or of advanced degeneration of the myocar- 
dium. When the right ventricle is much distended and the 
evidences of venous stasis are marked, the drug may fail to 
act until the tension in the veins has been lessened by the 
abstraction of a few ounces of blood. 

In mitral stenosis digitalis is far less serviceable than it is in 
mitral regurgitation. It should be used only when, as the 
result of a failing right ventricle, dropsy and anuria are 
present. Theoretically, by strengthening the contractions of 
the right ventricle, and by lengthening diastole, so allowing 
a longer time for blood to enter the left ventricle through the 
constricted orifice, it should be effective in lessening venous 
stasis, but unfortunately, in many cases of mitral stenosis, 
there is extensive disease of the myocardium, and in the 
presence of the latter — which in all forms of endocarditis is 
more important than the mere mechanical defect in the valve — 
digitalis is often useless or harmful. 

In aortic stenosis digitalis is rarely indicated, and used inju- 
diciously it may provoke serious injury. When, however, 
there are symptoms of back-pressure in the lungs, with 
dropsy, it may be employed with advantage. 

The existence of aortic regurgitation is not necessarily a con- 
traindication to the employment of digitalis. It is true that by 
prolonging diastole regurgitation is favored, but under certain 
conditions the drug more than compensates for this draw- 
back by strengthening the contractions of the ventricle, and 
by improving the tone of the myocardium. It should be with- 
held when the pulse is slow, full, and regular, but when the 
pulse becomes rapid, weak, and irregular, and symptoms 
of venous stasis appear, it may be administered tentatively. 

In tricuspid regurgitation not dependent upon disease of the 
valves, but due to simple dilatation of the right ventricle, 
digitalis is sometimes effective, but when used too freely it 
may excite, as Potain has observed, pulmonary hemorrhage. 

In advanced fatty degeneration digitalis often entirely fails 
or acts unfavorably, but in the early stages of the disorder the 
exhibition of minute doses, as recommended by Balfour, is 
often followed by gratifying results. In these cases it is nearly 
always necessary to counteract the constricting effect of the 
drug on the arterioles by giving with it some vasodilator, 
like nitroglycerin, sodium nitrite, or potassium iodid. When 
symptoms of angina pectoris are present, digitalis must be used 
with extreme caution, but even here small doses are some- 



52 CIRCULATORY STIMULANTS. 

times of value in the intervals between the attacks, and espe- 
cially after severe attacks, when symptoms of cardiac failure 
present themselves. 

In pneumonia, when there is failure of the right ventricle in 
its efforts to drive blood into the partially consolidated lung, 
and in consequence the pulse becomes rapid and feeble, digi- 
talis often causes a decided improvement in the symptoms. 
In such cases it has seemed to us to be more effective when 
given hypodermically. 

As a Vagus Stimulant. — In Graves's disease digitalis some- 
times quiets the heart and lessens the pulse-rate, but generally 
its action is disappointing, and in not a few cases it is badly 
borne. In the irritable heart resulting from overwork, and in 
arhythmia dependent upon simple dilatation, it is often of great 
service, but in nervous palpitation and paroxysmal tachycardia 
it rarely affords relief. 

As a Diuretic. — We regard digitalis as the most valuable 
remedy we possess in cardiac and renal dropsy. The best 
results are obtained when the pulse is soft and rapid. In 
hepatic dropsy, in common with other diuretics, it often proves 
useless. In pleural effusion and in other inflammatory transu- 
dations it is rarely of value. 

Contraindications. — Digitalis is contraindicated in aneu- 
rysm, advanced degeneration of the myocardium, and well- 
developed atheroma. 

Administration. — For general use the tincture is the most 
reliable preparation ; as a diuretic, however, some prefer the 
infusion. When digitalis is not well borne by the stomach, or 
when a prompt action is desired, digitalin may be given hypo- 
dermically. When it is desirable to give the drug in pill form 
the powdered leaves or the extract will be found convenient. 
In cardiac or hepatic dropsy it may be advantageously com- 
bined with mercury, as in the well-known Niemeyer's pill : 

R Pulveris digitalis, 

Pulveris scillse, 

Massse hydrargyri, aa gr. xx (1.3 gm. ). — M. 

Fiant pilulae, No. xx. 
Sig. One thrice daily after meals. 

In renal dropsy the following combination of digitalis with 
juniper and potassium acetate is well thought of: 

JJ Junip. contus., ^x (40.0 gm.) ; 

Pulv. scillse, 3J (30.0 gm. ) ; 

Pulv. digitalis, £j (4.0 gm. ) ; 

Vin. xerici, Oj (J liter). 
Macerate for four days and add : 

Potass, acetatis, giij (12.0 gm.). — M. 
Express and filter. 
Sig. Tablespoonful three times a day. 



ST£ OPHANTHUS. 5 3 

Patients taking digitalis should be seen at frequent inter- 
vals, on account of the suddenness with which untoward symp- 
toms may develop during its administration. When large 
doses are being used it is essential that the patient should be 
confined to bed. While some patients can take small doses 
of digitalis with advantage for long periods without inter- 
rupting the treatment, it nevertheless is advisable in most 
cases to suspend the administration every six or seven days 
for a like period, employing in the interval some alternate, 
such as cafTein, strophanthus, or convallaria. 

Incompatibles. — Digitalis is incompatible with prepara- 
tions containing tannic acid. With iron salts it forms an inky 
mixture. 

STROPHANTHUS, U. S. P. 

Strophanthus is the seed of Strophanthus Kombe, a native of 
Africa. It contains a glucosid, strophanthine which represents, 
in a measure, the therapeutic properties of the drug. This 
principle appears as a white, amorphous, or crystalline powder, 
of an intensely bitter taste, and soluble in water and alcohol. 

Preparations. Dose. 

Tinctura Strophanti, U. S. P 3-10 min. (0.18-0.65 c.c). 

Strophanthinum, U. S. P TF0~F& S 1 *- (0.0006-0.0013 gm.). 

Physiologic Action. — Strophanthus has an action very 
similar to that of digitalis ; like the latter, it slows the pulse, 
stimulates the heart, raises the blood-pressure, and increases 
the flow of urine. There are, however, certain points of differ- 
ence in the action of the two drugs : (1) Strophanthus con- 
stricts the vessels of the splanchnic area, but has little or no 
action on the peripheral vessels ; (2) it is diuretic even in nor- 
mal animals, probably because it is without influence on the 
renal arteries ; (3) it is a more powerful muscle poison than 
digitalis ; (4) it is absorbed more rapidly than digitalis, and, in 
consequence, is less irritant to the stomach; (5) it is eliminated 
more rapidly than digitalis, and, therefore, its action is less 
likely than that of the latter to become cumulative. 

Therapeutics. — Strophanthus is a valuable cardiac tonic, 
and may be employed in the class of cases in which digitalis 
is indicated ; it is more prompt in its action, but, as a rule, it 
is less reliable than the latter. It may be recommended when- 
ever the older remedy fails, or is not well borne, or when an 
alternate is desired. 

Contraindications. — The contraindications to the use of 
strophanthus are the same as those referred to in connection 
with digitalis. 



54 CIRCULATORY STIMULANTS. 

CAFFEINA, U. S. P. 

(Caffein.) 

Caffein is an approximate principle obtained from the leaves 
of Thea sinensis, or from the seeds of Coffea arabica. It ap- 
pears in the form of colorless, fine, silky crystals, having a 
bitter taste and a neutral reaction, and soluble in about 46 
parts of cold water. The drug is freely soluble in solution of 
sodium benzoate and sodium salicylate. 

Preparations. Dose. 

Caffeina Citrata, U. S. P 2-5 gr. (o. 1 3 -0.3 gm.). 

Caiieina Citrata Effervescens, U. S. P 1-2 dr. (4.0-8.0 gm.). 

Caffeinae Sodio-benzoas (45 percent, of caffein), 5-10 gr. (0.3-0.6 gm.). 

Physiologic Action. — Circulatory System. — The actions 
of caffein on the circulation are more or less antagonistic to 
one another. The drug tends to increase the rate of the heart 
by acting directly on the heart-muscle, and to decrease it by 
stimulating the inhibitory center in the medulla oblongata. 
Again, it tends to raise the arterial pressure (1) by increasing 
the efficiency of the heart itself, and (2) by stimulating the vaso- 
motor center (vasoconstriction) ; on the other hand, it tends to 
lower the arterial pressure by directly dilating, to some extent, 
the peripheral vessels. The total effect of therapeutic doses is 
generally to increase the rate of the heart and, also, slightly 
the output of blood per unit of time. 

After very large doses the contractions follow each other so 
rapidly that the ventricle has not time to fill, the blood-pressure 
falls, delirium cordis ensues, and the heart stops in diastole. 

Nervous System. — Caffein is a powerful cerebrospinal stim- 
ulant. In man the cerebrum is first affected, then the medulla, 
and, lastly, the spinal cord. Even small doses increase mental 
activity, quicken perception, induce wakefulness, and lessen 
fatigue. In the medulla the drug stimulates not only the vaso- 
motor and cardio-inhibitory centers but also the respiratory 
center. Its effects on the spinal cord are seen in mammals 
only after the administration of relatively large doses. They 
are indicated by an increase in the reflex excitability and the 
occurrence of tetanic convulsions. 

Muscles. — Small amounts of caffein increase both the irrita- 
bility and working power of all forms of muscle. Large 
amounts bring about a condition of rigor, which is shown by 
the fibers becoming contracted, hard, and opaque. 

Respiratory System. — Caffein is a powerful stimulant to 



CAFFEINA. 55 

the respiratory center. Under its influence both the number 
and depth of the respirations are increased. 

Kidneys. — Under favorable conditions caffein increases very 
decidedly the secretion of urine. The increase involves the 
output of water to a much greater extent than that of the 
solids, hence the specific gravity of the urine falls. Caffein 
diuresis is, probably, due to a direct stimulation of the renal 
epithelium, though some pharmacologists ascribe it to a dilata- 
tion of the renal arterioles of peripheral origin. It is certainly 
not the result of any changes in the general circulation. 

Alimentary Canal. — Caffein is rapidly absorbed, and, except 
in very large doses, is without action on the alimentary canal. 

Elimination. — Only a small quantity of the caffein ingested 
is secreted in the urine unchanged. To a great extent the drug 
is eliminated as di- and mono-methylxanthins. A very small 
amount is oxidized to urea. 

Toxicology. — The characteristic symptoms of caffein-poi- 
soning are mental excitement followed by delirium, palpitation, 
rapid breathing, frequent urination, intestinal colic, numbness 
of the extremities, tremors, convulsions, and, finally, collapse. 

Therapeutics. — Generally speaking, caffein is a far less 
useful remedy in valvular lieart disease than digitalis. When 
there is marked dropsy, however, a combination of caffein and 
digitalis often acts more favorably than either drug alone. In 
combating cardiac insufficiency in pneumonia and other infec- 
tive processes, it is usually more effective than digitalis. 

Being a direct diuretic, it often affords relief in chronic par- 
enchymatous nephritis with dropsy \ when digitalis fails. In chronic 
interstitial nephritis, when the left ventricle dilates and, in con- 
sequence, the secretion of urine falls off, dyspnea develops, and 
dropsy appears, it is sometimes serviceable. In acute pulmonary 
edema a combination of caffein and atropin may have a very 
happy effect, especially if administered hypodermically. 

As a respiratory stimulant it is valuable in poisoning by 
opium and other drugs which depress the respiratory center. 
In combination with phenacetin or one of the bromids it will 
often afford relief in migraine and headache from nervous strain. 

Contraindications. — It is contraindicated in all conditions 
associated with troublesome insomnia. In some persons even 
small doses, when administered late in the day, cause wake- 
fulness at night. 

Administration. — Since caffein and citrated caffein are 
readily decomposed in the presence of water, they are gen- 
erally prescribed for internal use in pills, powders, or capsules. 
When a prompt action is desired the drug should be given 



5 6 CIRCULA TOR Y STIMULANTS. 

hypodermically, and for this purpose the sodiobenzoate of 
caffein, as it is freely soluble and quite stable in solution, will 
be found a suitable preparation. The following formulae will 
illustrate the method of prescribing caffein : 

R Cafifeinse citratse, gr. xxiv (1.6 gm.); 

Acetanilidi, £j (4.0 gm. ). — M. 

Fiant chartulse, No. xii. 
Sig. One every two hours. (In nervous headache.) 

R Caffeinae, gr. xlviii (3.0 gm.) ; 

Sodii benzoatis, gij (8.0 gm.). — M. 

Fiant chartulae, No. xii. 
Sig. One every four hours. (In chronic nephritis with dropsy.) 

R Caffeinae sodio-benzoatis, gr. xij (0.8 gm.) ; 
Aquae destillatae, gj (4 c.c.). — M. 

Sig. 20 minims = 4 grains, or I c.c. =0.2 gm. 

CONVALLARIA, U. S. P. 

(Lily of the Valley.) 

Convallaria is the rhizome and roots of Convallaria majalis. 
It contains two glucosids, convallarin and convallamarin. 

Convallarin, being a saponin (see p. 19), is not absorbed 
from the alimentary canal, and, therefore, the value of the drug 
as a cardiac stimulant depends chiefly upon the convallamarin. 

Preparations. Dose. 

Fluidextractum Convallariae, U. S. P. . . 5-20 min. (0.3-1.2 c.c). 
Convallamarin \-\ gr. (0.03-0.065 gm.). 

Physiologic Action and Therapeutics. — The results 
obtained from the study of the physiologic action of conval- 
laria are somewhat conflicting, but clinical experience indicates 
that it acts much like digitalis in stimulating the heart and 
increasing the flow of urine. It has the advantages of not 
having any cumulative effect, and of not disturbing the stom- 
ach. Most authorities, however, agree that, as a rule, its 
action is inferior to that of digitalis, but that it sometimes gives 
excellent results in cases in which the latter remedy has 
failed. Its best effects are seen in the dropsy of heart-disease. 

Administration. — Convallaria should be prescribed only 
in the form of the fluid extract, since the convallamarin of 
commerce is a variable product. 

ADONIDIN. 

Adonidin is a glucosid obtained from the Adonis vernalis, a 
perennial plant indigenous to Central Europe and Asia. It is 
an amorphous, yellow or brown, odorless powder, having an 



OTHER CIRCULATORY STIMULANTS. 57 

intensely bitter taste. It is soluble in water and alcohol. The 
dose is from -jV" i S r - (0.005-0.01 gm.). 

Physiologic Action. — Adonidin affects the circulation 
somewhat like digitalis. It slows the pulse, probably by stim- 
ulating the vagi, and increases the arterial pressure probably 
by stimulating both the heart and the vasomotor center. Its 
action is more prompt than that of digitalis, but not so pow- 
erful. It does not seem to have any cumulative action. 
When the arterial pressure is low, adonidin causes some 
increase in the quantity of urine, but the drug apparently 
exerts very little influence on the kidney itself. Overdoses 
may cause nausea, vomiting, and diarrhea. 

Therapeutics. — Adonidin is used in about the same class 
of cases as digitalis. While generally less reliable than digi- 
talis, it may be employed as a substitute when the older 
remedy is badly borne or is ineffective. Oliver speaks favor- 
ably of its action in aortic regurgitation. 

OTHER CIRCULATORY STIMULANTS* 1 

lather (see p. 118). — In ordinary doses ether by the mouth 
or skin has little direct action on the heart, but through its 
local irritant effects it reflexly quickens the pulse and slightly 
raises the blood-pressure. On account of the promptness of 
its action it is a useful remedy in sudden heart-failure , as in 
shock, poisoning, and collapse of cholera, and other infections. 
In these cases it may be. given hypodermically in doses of from 
15-30 min. (1.0-2.0 c.c.). 

Nitrites. — Nitroglycerin, amyl nitrite, sodium nitrite (see p. 
69) affect the circulation in a similar manner, but differ in the 
rapidity and duration of their action, that of nitrite of amyl being 
the most rapid, but the least persistent, and that of sodium nitrite 
being the least rapid, but the most persistent. They quicken 
the pulse by stimulating the vagus center in the medulla oblon- 
gata and lower the blood-pressure by depressing the muscle 
of the arteries and thus causing vasodilation. The value of 
these drugs in diseases of the circulatory system is not due to 
their action on the heart itself, but to the relief they afford to 
the heart in diminishing the resistance in the peripheral vessels. 
They are especially useful in valvular diseases, when there is 
precordial distress and increased pulse-tension. When there is 
myocardial degeneration they may be combined advanta- 
geously with small doses of digitalis, in order to counteract the 
constricting effect of the latter on the blood-vessels. The 

1 The properties of these drugs are more fully considered under other headings. 



58 OTHER CIRCULATORY STIMULANTS. 

dyspnea, headache, and precordial discomfort attendant upon 
chronic nephritis with arteriosclerosis are often relieved by a 
nitrite. Inhalations of amyl nitrite are exceedingly efficacious 
in the paroxysms of angina pectoris. 

When a very prompt action is desired, nitrite of amyl (3- 
5 drops) may be given by inhalation. Nitroglycerin may be 
given in the form of the official 1 per cent, alcoholic solution, 
the dose of which is 1-2 min. (0.06-0.1 c.c), cautiously 
increased, or in the form of tablets containing a dose of from 
2< U 5*0 S r - (0.0003-0.001 gm.). 

On account of the marked variation in individual suscepti- 
bility small doses should be administered at first, and these 
gradually increased until the limit of tolerance is reached. 

Camphor (see p. 132). — Camphor is a useful diffusible car- 
diac stimulant in adynamic fevers. It not only serves to 
strengthen the pulse, but it also acts favorably in lessening the 
restlessness and delirium. It is best given hypodermically in 
doses of J— 2 gr. (0.03-0.13 gm.), dissolved in sterilized olive oil. 

Squill (see p. 224). — Squill closely resembles digitalis in 
its action on the circulation. It is also an efficient diuretic, 
acting partly by increasing the quantity of blood flowing 
through the kidneys and partly by directly stimulating the 
renal epithelium. Its irritant effect on the stomach, however, 
is especially pronounced, and for this reason it was at one time 
used in large doses as an emetic. In smaller doses it is a 
favorite expectorant. 

In valvular heart disease it is chiefly employed as an adju- 
vant to digitalis when there is persistent dropsy. In such cases 
the combination of blue mass, powdered squill, and digitalis, 
known as Niemeyer's Pill (see p. 52), is commonly prescribed. 
Owing to its expectorant properties, squill is frequently effica- 
cious also in clironis bronchitis with emphysema and dilated 
right heart. 

Apocynum (see p. 225). — This drug has the same qualitative 
action as digitalis, but as it is more irritant to the stomach and 
intestines than the latter, it is less serviceable as a cardiac 
stimulant. The fluidextract is sometimes given in doses of 
from 5 to 10 min. (0.3-0.6 c.c.) in valvular disease when there 
is much dropsy. 

Cactus Grandiflorus. — This drug has been employed for 
a number of years as a substitute for digitalis in various func- 
tional and organic diseases of the heart. The experimental 
evidence, however, does not support the view that it has a 
digitalic action, nor are clinicians in accord as to its therapeutic 
value. It is usually prescribed in the form of a fluidextract 



CIRCULATORY DEPRESSAXTS. 59 

made of the fresh plant, the dose of which is from 10 to 30 
minims (p.60-2.0 c.c). 

Adrenalin (see p. 66). — When injected directly into a vein, 
adrenalin slows the pulse and causes a marked increase in the 
blood-pressure. The first of these effects is due chiefly to 
stimulation of the cardio-inhibitory center in the medulla, and 
the second, partly to the direct action of the drug on the heart 
itself and partly to its powerful constricting effect on the pe- 
ripheral vessels. These effects of adrenalin on the circulation 
are prompt but evanescent, and are pronounced only when the 
drug is given intravenously. Administered in this way (i 
part of adrenalin chlorid to 50,000 parts of normal salt solu- 
tion) it is sometimes useful in maintaining the arterial pressure 
in shock and collapse, the result of severe injury or operation. 

Strychnin (see p. 141) in full medicinal doses raises the 
arterial pressure by stimulating the vasomotor center in the 
medulla. This action, together with its influence on the 
respiration, digestion, and muscle tonus, renders it a valuable 
remedy in combating certain forms of circulatory depression. 
Administered hypodermically, it is of considerable benefit in 
surgical shock. In simple dilatation of the heart, with or with- 
out valvular disease, it is often of the greatest service as an 
adjuvant to digitalis. In pneumonia and other infective proc- 
esses it may prove more useful than digitalis. In the weak 
heart of the old, also, it is generally a better remedy than 
digitalis. In chro?iic bronchitis with emphysema it is indispens- 
able in supporting the circulation and respiration. 



CIRCULATORY DEPRESSANTS. 

Circulatory- depressants are drugs which lessen the activity 
of the heart. They decrease the output of the heart per unit 
of time. Some of them act by directly depressing the cardiac 
muscle. As samples of this group may be mentioned : 

Chloral. Chloroform. Potassium salts. 

Others act by stimulating the inhibitory mechanism of the 
heart. The most important members of this group are : 

Aconite. Yeratrum. 

Reduction of Blood-pressure. — A drug may lower the 
blood-pressure (1 ) by decreasing the output of the heart per 



60 CIRCULATORY DEPRESSANTS. 

unit of time (cardiac depressants and vagal stimulants), (2) by- 
decreasing the quantity of fluid in the vessels (venesection), (3) 
by decreasing the resistance in the peripheral vessels (vaso- 
dilators and purgatives). 

Reduction of the Pulse-rate. — The action of the heart 
may be slowed (1) by directly stimulating the inhibitory mechan- 
ism in the medulla (digitalis, aconite, veratrum) ; (2) by raising 
the blood-pressure and thus indirectly stimulating the inhibitory- 
mechanism in the medulla (adrenalin, in part through vaso- 
constriction). Depression of the excitomotor apparatus would 
also tend to lessen the frequency of the heart's contractions, 
but no drug is known which in therapeutic doses has this effect. 

The only drugs employed as circulatory depressants are 
those which act by stimulating the vagal mechanism, namely, 
aconite and veratrum. These are indicated when the action of 
the heart is unduly forcible. Thus they may be of service in 
sthenic fevers, in acute local inflammation, in valvular disease 
when there is excessive hypertrophy of the heart, and in 
aneurism when the tension in the arteries is very high. 

ACONITUM, U. S. P. 

(Monkshood.) 

Official aconite is the root of Aconitwn Napellus, a perennial 
herb growing in Europe, Asia, and North America. The root 
is conical in shape, 2 or 3 inches long, brownish in color, and 
closely resembles horse-radish ; from this, however, it may be 
distinguished by its lack of pungent odor when scraped. 
When slowly chewed, it produces in the mouth a sense of 
warmth and tingling, soon followed by numbness. 

Active Principle. — The most important principle of aco- 
nite is aconitin (aconitina, U. S. P.), a crystalline alkaloid,, very 
sparingly soluble in water, but more freely so in dilute acids 
and alcohol. The amorphous aconitin of commerce is a 
mixture of alkaloids of variable strength, but much weaker 
than the official variety. The dose of crystalline aconitin is 

600 250 g r - (O.OOOI 1-0.00025 g m -)« 

Preparations. Dose. 

Tinctura Aconiti, U. S. P 5 _I 5 m i n > (0.3-1.0 c.c. ). 

Fluidextractum Aconiti, U. S. P. . . . 1-2 min. (0.06-0.12 c.c). 
Linimentum Aconiti. 

Physiologic Action. — Local Action. — Aconitin in aque- 
ous solution is not absorbed from the unbroken skin, but if 
rubbed in with fat, alcohol, or chloroform it produces first a 



ACONITUM. 6 1 

tingling sensation, then numbness, and, finally, anesthesia. From 
all mucous membranes it is readily taken up, so that the 
merest trace applied to the tongue induces almost immediately 
the characteristic tingling and numbness. Even when the drug 
is admininistered by the mouth or subcutaneously the same 
phenomena occur after absorption, chiefly, however, in the 
tongue, lips, throat, and finger-tips. This peculiar effect of 
aconitin on the skin and mucous membranes is the result of its 
selective action on the sensory nerve-endings. These are first 
stimulated and then paralyzed. Even in concentrated form 
the drug does not induce redness or other signs of inflam- 
mation. 

Circulatory System. — From a therapeutic standpoint the 
dominant circulatory action of aconite is on the vagus. Mod- 
erate doses in mammals slow the pulse, lower the blood- 
pressure, and decrease the output of the heart per unit of time. 
These effects are the result of powerful stimulation of the 
inhibitory centers in the medulla. They can be prevented by 
section of the vagi and even by the application of atropin. 

Toxic doses accelerate the heart's action, cause extreme 
auriculoventricular arhythmia, and finally bring on delirium 
cordis. These phenomena seem to be due to the direct action 
of the drug on the heart-muscle, since they occur after division 
of the vagi and also in the isolated heart. It is probable that 
aconite first stimulates and then depresses the vasomotor 
center. This action, however, is entirely overshadowed by 
that on the inhibitory cardiac mechanism. 

Effects of Aconite and Digitalis on the Circulation 
Compared. — Both drugs in medicinal doses slow the heart by 
stimulating the vagus, but digitalis, owing to its very pro- 
nounced action on the vasomotor center, blood-vessel walls, 
and heart, raises the arterial pressure and increases the output 
of the heart per unit of time. 

Respiration. — After large doses of aconite the breathing 
becomes slower, more labored, and sometimes dyspneic. 
These phenomena have been ascribed to broncho-constriction 
from stimulation of the vagal endings in the lungs, but in 
addition to this there appears some depression of the respira- 
tory center, for ultimately death results from asphyxia. 

Nervous System. — Apart from its action on the medullary 
centers, aconite does not seem to have any important influence 
on the central nervous system. The convulsions sometimes 
seen after toxic doses are probably the result of asphyxia. In 
poisoning the mind generally remains clear until near the end, 
though occasionally unconsciousness occurs early from col- 



62 CIRCULATORY DEPRESSANTS. 

lapse. Certain other endings besides those of the sensory 
nerves, notably the motor endings in striped muscle, appear to 
be excited by the drug. 

Secretions. — It is doubtful whether aconite has any direct 
action on the nerve-endings of the secretory glands. The 
excessive flow of mucus following the introduction of the drug 
into the nostrils or mouth is excited reflexly by irritation of 
the sensory nerve-endings, and the free perspiration observed 
in poisoning is probably the result of collapse. 

Digestive Tract. — Toxic doses of aconite not rarely cause 
nausea, vomiting, or purging. These are, no doubt, reflex 
effects. Minute doses may allay vomiting by benumbing 
the sensory nerve-endings of the stomach. 

Temperature. — Aconite lowers temperature to a certain 
extent, both in health and in febrile states, but the manner of 
antipyretic action is not definitely known. It is believed, how- 
ever, that the drug has some influence on the heat-regulating 
centers. 

Toxicology. — The symptoms develop very rapidly after 
the injection of the poison. Among the first to appear is the 
characteristic tingling, which, beginning in the lips, tongue, and 
throat, soon spreads to the fingers and toes, and at last involves 
the whole surface. This is accompanied by excessive saliva- 
tion, and sometimes by nausea, vomiting, and purging. The 
pulse, at first infrequent and soft, later becomes extremely fre- 
quent, weak, and irregular. The breathing is slow and labored. 
The skin is cool, livid, and covered with sweat. The mind is 
usually clear until near the end, but sometimes unconscious- 
ness occurs rather early in consequence of the profound col- 
lapse. Death, which is generally the result of respiratoiy 
failure, is not rarely preceded by convulsions. 

Treatment. — This consists in keeping the patient in the 
recumbent posture, with the feet somewhat higher than the 
head; in washing out the stomach, if necessary; in the main- 
tenance of the bodily temperature by external application of 
heat; and the administration hypodermically of ammonia, 
brandy, and atropin, especially of the latter, which in several 
respects is antagonistic to aconitin. 

Therapeutics. — In the early stages of acute inflamma- 
tions, such as tonsillitis, pharyngitis, laryngitis, and bronchitis, 
and in the beginning of the acute infectious diseases of child- 
hood, aconite is often very useful in quieting the circulation and 
lowering the temperature. In excessive hypertrophy of the 
heart it sometimes acts favorably. In acute cerebral congestion, 
with high arterial tension, it may be given in full doses. In 



VERATRUM. 63 

tachycardia and palpitation it is of little value unless these 
symptoms be associated with hypertrophy of the heart. Small 
doses (J- drop), at frequent intervals, are sometimes efficacious 
in hyperemesis. An ointment of aconitin (5-10 gr. to the 
ounce — 0.3-0.6 to 30.0 gm.) was formerly much used as a 
local remedy in neuralgia. The liniment of aconite, official 
in the British Pharmacopoeia, is often beneficial in muscular 
rheumatism. 

Administration. — The tincture is the preparation most 
commonly selected for internal use; small doses should be 
given in water, frequently repeated, and the effect watched. 
Aconitin, on account of its pronounced toxicity, is rarely given 
internally. If used externally, care should be taken to avoid 
the eye, as the drug is highly irritating. On cutaneous sur- 
faces, provided there are no abrasions, it may be applied with 
safety. The following time-honored combination is efficient in 
the mild febrile diseases of childhood : 

$t Tincturse aconiti, Tltxv (1.0 c.c.); 

Spiritus setheris nitrosi, i%\) (23.0 c.c.) ; 

Liquoris ammonii acetatis, q. s. ad f^iij (90.0 c.c). — M. 
Sig. A teaspoonful every two or three hours for a child of two years. 

VERATRUM, U. S. P. 

(Green Hellebore or White Hellebore.) 

Under one title, veratrum, the United States Pharmacopoeia 
of 1906 recognizes the rhizome and roots of Veratrum viride 
and of Veratrum album. The former is a native of North 
America and the latter of Europe. While the action of the 
two plants is very similar, it is not known to be identical. 
White hellebore, the European variety, is apparently the more 
toxic of the two. Both plants contain a number of alkaloids. 
Veratrin appears to be the most active of those present in 
veratrum viride, and protoveratrin of those present in Veratrum 
album, though this is not certainly established. 

The official veratrin is obtained from the seed of Asagrcea 
officinalis, a bulbous herb growing in Mexico and Central Amer- 
ica. It is a mixture of pure veratrin and a number of other 
less active alkaloids. 

Preparations. Dose. 

Tinctura Veratri, U. S. P 5-15 min. (0.3-1.0 c.c. ). 

Fluidextractum Veratri, U. S. P. . . . 1-3 min. (0.06-0.2 c.c). 
Unguentum Veratrinoe, U. S. P. (4 per cent.). 
Oleatum Veratrinae, U. S. P. (2 per cent.). 



64 CIRCULATORY DEPRESSANTS. 

Physiologic Action. — Veratrum very closely resembles 
aconite in most of its actions. In moderate doses it produces 
a distinct slowing of the pulse, with some lowering of the 
blood-pressure. These phenomena are mainly attributable to 
stimulation of the cardiac inhibitory center. Very large doses, 
after first slowing the pulse, suddenly accelerate it and at the 
same time induce extreme arhythmia, with an enormous fall of 
blood-pressure. The acceleration of the pulse appears to be 
due in part to paralysis of the peripheral vagi and in part to 
stimulation of the cardiac muscle. The progressive fall of the 
arterial pressure observed in late poisoning is caused by de- 
pression of the vasomotor center and of the myocardium itself. 

Like aconite, veratrum also depresses the respiration and 
lowers the temperature. 

Special Action of the Alkaloids. — Of the alkaloids, 
veratrin has a characteristic effect on muscle, both striated 
and unstriated. Under its influence, the muscle, when stimu- 
lated, contracts as rapidly as usual, but more vigorously, and, 
once contracted, requires from twenty to thirty times the normal 
time to relax again. Further, the drug increases the irritability 
of muscle and restores to some extent its contractility, when 
this has been lost through fatigue. These effects are thought 
to be due to increased catabolism. Like aconitin, veratrin first 
irritates and then depresses the sensory nerve-endings, hence 
local applications of the drug give rise in turn to tingling, 
numbness, and anesthesia. Inhaled, it causes violent sneezing, 
coughing, and increased secretion of mucus. Large quantities 
also paralyze the motor nerve-endings, but without stimulating 
them first. The vomiting and purging constantly observed in 
veratrin-poisoning are probably produced reflexly by irritation 
of the sensory nerve-endings. 

Pj'otoveratrin, while it increases the strength of muscular 
contractions, does not prolong the contractions, but rather 
shortens them. It is even more depressant to sensory nerve- 
endings than veratrin, but it has no paralyzant effect on motor 
nerve-endings. 

Toxicology. — Veratrum-poisoning resembles aconite- 
poisoning, but is generally marked by more severe gastro- 
intestinal symptoms. 

Therapeutics. — In excessive hypertrophy of the heart, with 
or without valvular lesions, veratrum is a useful circulatory 
sedative. In aneurism, when there is much pain and the pulse 
is full and strong, veratrum, in conjunction with potassium 
iodid and rest, often affords relief. In the beginning of acute 
inflammatory diseases it may replace aconite as a cardiac seda- 
tive and febrifuge. 



OTHER CIRCULATORY DEPRESSANTS. 65 

In the first stage of croupous pneumonia of a sthenic type 
it may affect favorably the pulse and temperature, but it has no 
power of aborting the disease. In puerperal eclampsia, by 
lowering arterial tension, it often proves a valuable addition to 
other remedies. 

Veratrin, in the form of the official ointment or oleate, is 
occasionally used as a local remedy in neuralgia. It should 
never be applied over large surfaces or where there are any 
abrasions, and in employing it about the face great care must 
be exercised to keep it out of the eye. 

Contraindications. — Cardiac and systemic weakness and 
irritability of the stomach are the chief contraindications to 
its use. 

Administration. — The tincture is the best preparation ; it 
should be given at frequent intervals, the dose being cautiously 
increased until the physiologic effect is produced. 



OTHER CIRCULATORY DEPRESSANTS. 

Stavesacre. — This drug (Staphisagria, U. S. P.) is the seed 
of Delphinium Staphisagria, an annual herb growing in South- 
ern Europe. It contains several alkaloids, the chief of which 
is delphinin. The action of stavesacre is very like that of 
aconite, but the drug is rarely used at present except exter- 
nally for the destruction of pediculi. For this purpose the oil 
diluted with 8 parts of olive oil or an ointment of the crushed 
seed (20 per cent.) may be prescribed. The United States 
Pharmacopoeia recognizes a fluidextract of stavesacre, the dose 
of which is 1-2 min. (0.06-0.12 c.c). 

Pulsatilla. — This drug is the herb of Anemone Pulsatilla 
and Anemone prcetensis. It contains a colorless, crystalline, 
acrid principle, known as anemonin. The dose of the latter is 
from \-\ gr. (0.008-0.03 g m 0- The drug may be used also in 
the form of the tincture, the dose of which is 10-20 min. 
(0.6-1.2 c.c). 

Locally, pulsatilla acts as an irritant. Internally, large 
doses may cause vomiting and even purging. On the 
circulation its action is said to resemble that of aconite. 
Pulsatilla has been used as a circulatory sedative in acute 
inflammatory diseases, as a respiratory sedative in asthma, 
and as an emmenagogue, but as a therapeutic agent it is of 
little value. 



66 VASOCONSTRICTORS AND VASODILATORS. 

VASOCONSTRICTORS AND VASODILATORS. 

Vasoconstrictors are drugs that constrict the peripheral 
arterioles. They may act (i) by stimulating the vasomotor 
center in the medulla or (2) by contracting the vascular walls 
directly. A number of them act in both ways. Among those 
having a central action may be mentioned: 

Atropin. CafTein. Strychnin. 

The following act both centrally and peripherally: 

Digitalis. Ergot. Cocain. 

The best example of a peripheral vasoconstrictor is : 
Adrenalin. 

Vasoconstrictors raise the general blood-pressure, and, by 
increasing the tonus in the medulla, tend to lessen the fre- 
quency of the heart's action and to stimulate the respiration. 
As internal remedies they are especially indicated in conditions 
of low arterial tension, such as shock and collapse. Only 
adrenalin, which is chiefly used as a vasoconstrictor, will be 
considered in this chapter. 

Vasodilators are drugs that dilate the peripheral arterioles. 
They may act (1) by depressing the vasomotor center in the 
medulla or (2) by relaxing directly the vascular walls. The 
most important are : 

The nitrites. 

The organic nitrates (nitroglycerin, erythrol tetranitrate). 

These drugs act peripherally, and are employed to facilitate 
the passage of the blood through the vessels and to lower 
the arterial tension. 

ADRENALIN. 

The remarkable action of suprarenal extract on the circula- 
tion, which was first pointed out by Oliver and Schaefer, in 
1894, depends upon the alkaloid isolated by Abel, in 1896, and 
variously known as epinephrin, suprarenin, and adrenalin. 
With acids the alkaloid forms salts, of which the hydrochlorid 
is freely soluble in water. This salt may be obtained in crys- 



ADRENALIN. 67 

tals and in the form of a 1 : 1000 solution, preserved with some 
antiseptic. 

Physiologic Action. — When injected into a vein, even in 
small doses, adrenalin causes marked elevation of the blood- 
pressure and slowing of the heart-beat. The first of these 
effects is due mainly to constriction of the arterioles, especially 
those of the splanchnic area, and in part to stimulation of the 
cardiac muscle. The retardation of the heart-beat is due to 
stimulation of the vagus center in the medulla oblongata, 
directly by the drug itself and indirectly by the rise of blood- 
pressure. The vasoconstriction is chiefly, probably entirely, 
of peripheral origin, and the result of a stimulant action 
exerted either on the muscle of the arterioles or the sympa- 
thetic nerve-endings in the muscle. As perfusion of adrenalin 
through vessels which are not innervated by the sympathetic, 
as those of the lungs and brain, does not cause constriction, it 
is probable that the drug acts on the nerve-endings rather than 
on the muscle-fibers themselves. These effects of adrenalin 
on the general circulation are pronounced only after intra- 
venous injections ; after subcutaneous injections they are very 
slight, even with large doses, and after administration by the 
mouth they are not noticeable. Even after intravenous injec- 
tions they are very fugitive. The great variation in the action 
of the drug with these different methods of administration is 
to be ascribed to the slow absorption, on the one hand, and its 
rapid oxidation on the other. Locally, applied to mucous 
membranes or raw surfaces, it causes intense ischemia by 
directly constricting the peripheral vessels. Upon the un- 
broken skin it has no effect. 

Josue and others have shown that repeated intravenous 
injections of adrenalin in rabbits sometimes lead to degenerative 
changes in the aorta and larger arteries, resembling atheroma. 
Whether these changes are the result of a direct toxic action, 
increase of blood-pressure, or constriction of the vaso vasorum, 
has not been definitely determined. 

Upon plain muscle other than that of the vessels the action 
of adrenalin is not uniform. Thus, while it contracts the 
ureter, vas deferens, and seminal vesicles, and in the female, 
the uterus and vagina, it inhibits the movements of the 
stomach, bowel, and bladder. In the eye, the drug produces 
the effect of sympathetic excitation; namely, dilatation of the 
pupil, separation of the eyelids, and exophthalmos. It also 
promotes the secretion of certain glands, probably by stimu- 
lating the nerve-endings in their cells. Thus, it increases the 
tears, saliva, bronchial mucus, and bile. Injected intraven- 



68 VASOCONSTRICTORS AND VASODILATORS. 

ously or intraperitoneally, and particularly when applied 
directly to the surface of the pancreas, adrenalin produces 
temporary glycosuria. This is apparently the result of some 
obscure toxic action exerted directly on the cells of the 
pancreas. 

Therapeutics. — As the characteristic effects of adrenalin 
on the general circulation occur only with its intravenous 
administration, and even then are extremely fugitive, it follows 
that its field of usefulness as a circulatory stimulant must be a 
very limited one. It appears to be chiefly indicated in marked 
vasodilation with good heart muscle. Thus, in shock and col- 
lapse during anesthesia, it may prove life-saving. In these 
conditions 10 minims (0.6 c.c.) of the solution (1 : 1000) may 
be given intravenously, drop by drop ; or better, especially in 
shock, intravenous transfusion may be practised, using one 
part of the drug to 50,000 parts of normal salt solution. 

As a local vasoconstrictor adrenalin is of great value in 
relieving co7igestion and in checking hemorrhage. In operations 
on the eye, nose, and throat, solutions of 1 : 5000 to 1 : 1000 
not only prevent bleeding, but render anesthesia with cocain 
more complete, and at the same time lessen the danger from 
absorption of the anesthetic. In severe epistaxis prompt relief 
is usually afforded by plugging the nostrils with cotton soaked 
in a 1 : 1000 solution. In hematemesis benefit may be derived 
from the administration of to to 30 minims (0.6-2.0 c.c.) of a 
1 : 1000 solution in a tablespoonful of water every hour or 
half-hour. In distant hemorrhages, however, adrenalin is use- 
less. Solutions 1 : 10,000 to 1 : 5000 are sometimes efficacious 
in acute coryza and hay fever. Suppositories containing 1 part 
of adrenalin to 1000 of cocoa butter are recommended in 
bleeding hemorrhoids. The drug is said to relieve pain in vari- 
ous inflammatory diseases of the eye, but Lemare urges against 
its use when there is a tendency to iritis, contending that it 
may prove harmful by driving the blood from the surface to 
the deeper anastomosing vessels of the iris and ciliary body. 

Desiccated suprarenal glands (Glandulse Suprarenales Siccse, 
U. S. P.), in doses of 3-5 grains (0.2-0.3 gm.), thrice daily, 
have been shown to be of some value in Addison's disease. In 
most cases, however, the good effects have been only tempo- 
rary, and this is what we should have expected, knowing the 
incurable nature of the local lesions. One of Osier's patients 
gained nineteen pounds, the asthenia disappeared, and he was 
alive two years subsequently, but was still pigmented. Kinni- 
cutt has collected 48 cases treated with the extract. Of these, 
6 were reported cured and 22 as improved. In estimating the 



AMYLIS NJTRIS. 69 

value of these and similar statistics, due allowance should be 
made for the fact that favorable results are more likely to be 
published than those which are unfavorable. 

AMYLIS NITRIS, U. S. P. 

(Amyl Nitrite, C 5 H n N0 2 .) 

Amyl nitrite is prepared by distilling equal volumes of pure 
amylic alcohol and nitric acid. It appears as a yellowish, highly 
volatile liquid having a strong ethereal odor. 

Physiologic Action. — The inhalation of nitrite of amyl 
is speedily followed by flushing of the face, a sense of fulness 
in the head, quickening of the pulse, and a pronounced 
fall of blood-pressure. The flushing of the face and fall of 
blood-pressure are due to dilatation of the arterioles, which 
in turn is the result of the direct depressant action of the 
drug upon the vessel walls. The vasodilation is especially 
marked in the brain, abdominal organs, and u blush area " of 
the skin. The quickening of the pulse appears to be chiefly 
brought about by direct depression of the vagus center in the 
medulla oblongata, though it may be in part the result of the 
lowered blood-pressure, which tends to diminish the tonus in 
the medulla. Small doses do not affect the heart directly, but 
large doses depress it, exactly as they depress other forms of 
involuntary muscle. It is evident, therefore, that it is only by 
lessening resistance in the peripheral vessels that the nitrites 
can favorably influence the heart. 

Blood. — When mixed with a nitrite blood acquires a choc- 
olate color, owing to the transformation of oxyhemoglobin 
into methemoglobin. This compound is more stable than 
oxyhemoglobin!, and cannot act as an oxygen carrier. In 
man the amount produced by medicinal doses, however, is so 
small that no harmful effects are seen. The blood-cells them- 
selves are not injured, as with many other methemoglobin 
formers (coal-tar derivatives, potassium chlorate, pyrogallol), 
and in a short time the methemoglobin is reduced by the tis- 
sues and replaced by oxyhemoglobin. When present in the 
blood in large quantities methemoglobin gives rise to cyanosis 
and intense dyspnea. 

Respiratory System. — Moderate doses slightly increase the 
rate and depth of the respirations, probably by acting directly 
on the respiratory center. Very large doses decrease the fre- 
quency and depth of the respirations by depressing the center. 
Nervous System. — In man the nitrites have no direct 
action on the central nervous system. In frogs, however, 



JO VASOCONSTRICTORS AND VASODILATORS. 

they depress the spinal cord and lessen reflex excitability. 
The ringing in the ears, throbbing, and headache which follow 
the inhalation of amyl nitrite are the result of cerebral con- 
gestion. Convulsions are sometimes observed in poisoning, 
but they are probably due to asphyxia. 

Muscles. — Other forms of plain muscle, as that of the 
ureters, bronchioles, and intestines, are also relaxed by the 
nitrites, though not to the same extent as that of the blood- 
vessels. Striated muscle is only slightly effected. 

Temperature. — Some fall in temperature occurs after mod- 
erate doses, as a result of the dilatation of the cutaneous ves- 
sels and increased radiation 

Elimination. — Amyl nitrite undergoes oxidation in the 
body part being completely broken up and part being ex- 
creted in the urine as metallic nitrates and nitrites. 

Therapeutics. — Nitrite of amyl is employed chiefly for 
two purposes: To relax spasm and to lower arterial tension. 
Owing to the rapidity with which it is absorbed and eliminated, 
it is of service only when a very prompt but transitory effect 
is required. 

As an Antispasmodic. — Inhalations of amyl nitrite often 
prove servicable in arresting the convulsions of epilepsy, teta- 
nus, uremia, and strychnin-poisoning, though the manner of the 
drug's action is not apparent. When the seizures of epilepsy 
are preceded by an aura the patient may carry the remedy in a 
small bottle containing the exact dose, or in glass " pearls " 
made especially for the purpose. Amyl nitrite sometimes does 
good also in asthma and ivhooping-cough. 

As a Vasodilator. — On account of the fugaciousness of its 
action amyl nitrite is not so useful as nitroglycerin or erythrol 
tetranitrate in circulatory diseases associated with persistent 
high arterial tension. In attacks of angina pectoris, however, it 
often acts most happily. Curiously enough, the drug is just as 
likely to do good in this disease when the pulse is soft as when it 
is hard. Brunton explains this fact in the following way : The 
excessive work to be done, which is the cause of the pain, may 
be due either to the resistance in the vessels being increased 
above the normal, or to the power of the heart to overcome 
the resistance being lessened below the normal. In either 
case the resistance becomes too great for the heart. 

The vasodilator action of the drug has led to its use in 
malaria, to cut short the first stage of the paroxysms. It is 
said to be of service in migraine, when the pain is associated 
with constriction of the peripheral vessels. By lowering the 
general arterial pressure, it may also have a salutary effect in 
hemoptysis. 



AMYLIS NITRIS. ?l 

Administration. — Amyl nitrite is almost always given 
by inhalation : 2-5 min. (0.1-0.3 c.c.) maybe dropped upon 
a handkerchief, or one of the small glass capsules containing 
the requisite dose may be crushed in a handkerchief, and the 
vapor inhaled. According to Osier it sometimes acts better 
in angina pectoris when given by the mouth, combined with 
the tincture of capsicum and peppermint-water. As a rule, 
however, nitroglycerin is better suited for internal administra- 
tion. 

GLYCERYLIS NITRAS. 

(Nitroglycerin, Glonoin, Glyceryl Trinitrate, Trinitrin, C 3 H 6 (N0 3 ) 3 .) 

Nitroglycerin is prepared by gradually adding dehydrated 
glycerin to nitric acid, or a mixture of nitric and sulphuric 
acids. It is official in the form of a I per cent, (by weight) 
alcoholic solution (Spiritus Glycerylis Nitratis, U. S. P.), the 
dose of which is from 1-3 min. (0.06-0.2 c.c), cautiously in- 
creased until effects are manifested. The spirit should be kept 
in well-stoppered tin cans, and should be stored in a cool place, 
remote from lights or fire. Care must be exercised in handling 
it, since a dangerous explosion may occur if any considerable 
quantity be spilled. 

Physiologic Action. — The action of nitroglycerin is simi- 
lar to that of amyl nitrite, except that it is not quite so prompt, 
and is more persistent. Its effects are recognizable within a 
few minutes, and last, according to the dose, from one to two 
hours. 

Therapeutics. — In fatty and fibroid degeneration of the 
myocardium nitroglycerin is often a useful remedy, especially 
when there is precordial pain or oppression. In angina pectoris 
it is often of value when given between the paroxysms, alone 
or in conjunction with potassium iodid. In chronic valvular 
disease it is sometimes advantageous to give nitroglycerin 
along with digitalis in order to counteract the tendency of the 
latter to constrict the peripheral vessels. In such cases, how- 
ever, the two drugs should not be combined, since the action 
of the one is very prompt, but fugacious, while that of the 
other is slow, but persistent. No remedy equals nitroglycerin 
in relieving the high arterial tension, dyspnea, palpitation, head- 
ache, vertigo, and insomnia of chronic nephritis. On the other 
hand, in acute heart failure the drug may do harm by lowering 
still further the pressure in the coronary arteries, and in shock 
it is, of course, absolutely contraindicated. 

In small, frequently repeated doses nitroglycerin sometimes 
proves effective in controlling persistent hiccough. Wade rec- 
ommends it in the abdominal palpitations frequently seen in 



72 VASOCONSTRICTORS AND VASODILATORS. 

nervous women. He believes that it acts by lowering the blood- 
pressure in the splanchnic area. Good results occasionally 
follow its use in migraine and sciatica. Temporary relief is 
sometimes obtained from its use in the asphyxial stage of 
Raynaud's disease. It has also been highly recommended in 
hemoptysis. 

Untoward Effects. — In certain individuals the smallest 
dose of nitroglycerin induces flushing of the face, headache, 
tinnitus aurium, and vertigo. 

Administration. — It may be given by the mouth or sub- 
cutaneously. For internal use, the available preparations are 
the official spirit and the tablets, which are commonly found 
in the market, and which contain from ^^ gr. (o.oooi- 
0.0012 gm.). For subcutaneous injection either the spirit or 
soluble hypodermic tablets may be employed. It is very im- 
portant that the preparation should be fresh, as both solutions 
and tablets deteriorate with age. On account of the extreme 
variation in individual susceptibility to the drug, very small 
doses should be administered at first, and these gradually in- 
creased until the therapeutic or physiologic effect (flushing, 
etc.) is secured. According to Wood, a single drop has caused 
insensibility ; on the other hand, Whittaker has given as much 
as 8f gr. (0.56 gm.) in twenty-four hours without untoward 
effects. Toleration of the drug is rapidly acquired, and this is 
another reason for making the initial doses the smallest that 
will prove effective. 

ERYTHROL TETRANITRATE. 

(Tetranitrol, (CH 2 .ON0 2 ) 2 (CH.ON0 2 ) 2 .) 

Erythrol tetranitrate occurs in the form of large scales, 
which are soluble in alcohol, insoluble in water, and which 
readily explode on percussion. In the form of chocolate or 
cocoa-butter tablets, however, it may be handled with perfect 
safety. The dose is from \-2 gr. (0.03-0. 1 3 gm.). 

Physiologic Action and Therapeutics. — The action 
of erythrol tetranitrate closely resembles that of nitroglycerin, 
but it is milder and decidedly more prolonged. As in the 
case of the nitrites, patients vary considerably in their sus- 
ceptibility to the drug : \ gr. (0.03 gm.) has caused intense 
headache and great malaise lasting thirty-six hours ; on the 
other hand, so much as J dr. (2.0 gm.) in twenty-four hours 
has been given with good results. 

Erythrol tetranitrate is indicated in the same class of cases 
as nitroglycerin. On account of its prolonged action it is 
especially useful in arteriosclerosis, angina pectoris, chronic 
interstitial nephritis, and Raynaud's disease. 



RESPIRATORY STIMULANTS. 73 

SODII NITRIS, U. S. P. 

(Sodium Nitrite, NaN0 2 .) 

Sodium nitrite occurs in the form of white, opaque, fused 
masses, or colorless, transparent crystals, odorless, and of a 
mild saline taste. It is soluble in 1.4 parts of water, and 
sparingly soluble in alcohol. The dose is from 2-3 gr. (0.13- 
0.2 gm.). 

Therapeutics. — The action of sodium nitrite is identical 
with that of amy! nitrite, except that it is less rapid and more 
lasting. As a vasodilator it is not so reliable as erythrol 
tetranitrate, although it resembles that drug in the perma- 
nency of its effects. It is indicated in the same class of cases 
as erythrol tetranitrate and nitroglycerin. 



RESPIRATORY STIMULANTS. 

The following drugs stimulate the respiratory center in the 
medulla oblongata: 

Ammonia. Cocain. 

Strychnin. Atropin. 

Caffein. Aspidospermin. 

In addition to these drugs, external heat increases the depth 
of the respirations. The expiratory and inspiratory fibers of the 
vagus are stimulated by the rhythmic expansion and collapse 
of the lung, which takes place in the practice of artificial res- 
piration by Sylvester's method. In pursuing this method the 
patient is placed in a supine position ; his arms are drawn 
upward and outward so as to fully expand the chest ; after a 
pause of a few seconds the arms are brought down forcibly to 
the sides of the chest and pressed against them for a second. 
These movements are repeated about sixteen or eighteen 
times in a minute. The respiratory center may be stimulated 
also reflexly by irritating certain peripheral sensory nerves. 
Thus, in Laborde's method of treating asphyxia by rhythmic 
traction of the tongue, the center is affected through the sen- 
sory nerves of the tongue. This method consists in drawing 
the tongue outward and upward by means of forceps for from 
twelve to fourteen times a minute. 

The vapor of ammonia when inhaled stimulates the nasal 
branches of the fifth nerve, and thus reflexly excites the 
respiratory center. The use of the cold douche, the pouring 



74 CEREBRAL EXCITANTS. 

of ether on the bare chest, and the application of an electric 
current to the skin are also means of arousing the respiratory 
center through peripheral irritation. 

Drugs which stimulate the respiratory center are indicated 
in pulmonary affections associated with marked dyspnea, such 
as pneumonia , severe bronchitis, and emphysema ; and in poi- 
soning by drugs which cause asphyxia, such as opium and 
ether. 

The various measures by which the respiratory center is 
stimulated reflexly are especially indicated in poisoning. 



RESPIRATORY DEPRESSANTS. 

The following drugs depress the respiratory center : 

Opium (morphin, codein). Bromids. 

Chloral. Hyoscin. 

In addition to these drugs there are many others (aconite, 
veratrum, gelsemium, physostigma, belladonna, hydrocyanic 
acid, alcohol, ether, phenol, salicylic acid) that cause asphyxia 
in toxic doses. 

Certain of the respiratory depressants, notably opium and 
its alkaloids and the bromids, are employed in pulmonary 
diseases to allay coitgli. 



CEREBRAL EXCITANTS. 

Our knowledge concerning the action of drugs on the brain 
is very imperfect. We know, however, that certain of them 
stimulate the motor area, and in large doses cause an increase 
in movement and even epileptiform convulsions, while others 
affect chiefly the psychic centers and increase the capacity for 
intellectual work. To the first class belong : 

Atropin. Cocain. Cafifein. 

Heavy metals (lead, copper, silver) and certain volatile oils, 
especially camphor, oil of wormwood (absinth), oil of tansy, and 
oil of nutmeg, in toxic doses also cause epileptiform seizures 
by exciting the cerebral cortex. 

Cornutin (see Ergot) and picrotoxin in large doses induce 



BELLADONNA. 75 

convulsions, which are apparently due to intense excitation of 
the medulla oblongata, since they cease after removal of the 
latter, but persist after removal of the cerebrum. 

The chief representative of the second class of cerebral stim- 
lulants, or of those which act on the psychic centers of the brain 
is caffein. Cocain also stimulates the higher functions, but 
much less powerfully those of the lower centers, such as the 
motor. 

A number of drugs (alcohol, ether, atropin) cause more or 
less mental excitement, but at no time exert any real stim- 
ulant effect on the highest intellectual functions — attention, 
perception, judgment. The excitement is probably due to 
depression of the inhibitory or controlling centers of the 
brain. In large doses these drugs cause confusion of thought 
and delirium. 

A few of the cerebral excitants, particularly atropin, caffein, 
and cocain, are useful in arousing the cerebral centers when 
they have been profoundly depressed by poisons, such as 
opium. 

BELLADONNA. 

(Deadly Nightshade.) 

Belladonna is official as the leaves {belladonna folia) and as 
the root {belladonna radix) of Atropa Belladonna, a bushy 
perennial, a native of Europe, but largely cultivated in North 
America. The chief active constituents are the two alkaloids 
atropin and hyoscyamin, though a third alkaloid, hyoscin, is also 
present in minute quantities. Hyoscyamin is isomeric with 
atropin and is readily changed to it. Indeed, the preparations 
of belladonna apparently owe their activity very largely to 
atropin, which is official as Atrophia and Atropines sulphas. 
Both the alkaloids and its salts appear in the form of a 
white crystalline powder, having an acrid, bitter taste. The 
former is sparingly soluble in water, the latter in 0.4 part 
of water and 3.7 parts of alcohol. The dose of atropin is 
2W-T5 gr. (0.00032-0.00086 gm.); of atropin sulphate, yj-g-^ 
gr. (0.00043-0.0013 gm.). 

Preparations. Dose. 

Tinctura Belladonnse Foliorum, U. S. P. . . 5~ 2 ° min - (0.3-I.2 c.c). 
Extractum Belladonnas Foliorum, U. S. P. . . \-\ gr. (0.008-0.016 gm.). 
Fluidextractum Belladonnas Radicis, U. S. P., 1-3 min. (0.06-0.2 c.c). 
Emplastrum Belladonnas, U. S. P. 
Unguentum Belladonnas, U. S. P. (10 per cent.). 



76 CEREBRAL EXCITANTS. 

Physiologic Action. — When taken internally in large 
doses belladonna produces dryness of the throat, dilatation 
of the pupils, quickening of the pulse, elevation of tempera- 
ture, and sometimes talkative delirium and an erythematous 
rash. The rash generally appears on the face and neck and 
resembles that of scarlatina, but it lacks the characteristic 
punctations of the latter. 

Circulatory System. — In moderate doses atropin quickens 
the pulse, raises the arterial pressure, and increases the output 
of the heart per unit of time. The acceleration of the pulse is 
due to depression of the peripheral fibers of the vagus in the 
heart. Prior to the acceleration there is occasionally some slow- 
ing from stimulation of the inhibitory center in the medulla, but 
this effect is always transient. Because of the low tonus of the 
vagal fibers in the extremes of life little or no change in the 
pulse-rate follows the use of the drug in infants and old persons. 
The elevation of the blood-pressure is due in part to marked 
constriction of the splanchnic vessels from stimulation of the 
vasoconstrictor center in the medulla, and in part to accelera- 
tion of the heart-beat. While the abdominal vessels are con- 
stricted, however, those of the skin are dilated from excitation 
of the vasodilator center, hence the tendency to an erythema- 
tous rash in belladonna-poisoning. Large doses of atropin 
ultimately lower the blood-pressure by depressing the heart 
muscle. 

Respiratory System. — Moderate doses of the drug stimu- 
late the respiratory center and render the respirations quicker 
and deeper. Large doses paralyze the respiration. In fatal 
poisoning the breathing ceases before the heart-beat. 

Nervous System. — The action of atropin on the central 
nervous system is a complex one. In man, large doses cause 
restlessness and excitement, then talkative delirium, and, finally, 
stupor and coma. The first of these effects is probably due to 
stimulation of the brain, especially of the motor area, and the 
later ones to depression of the brain, first of the controlling 
centers and then of the psychic centers. In frogs, because of 
the poor development of the brain, the action of the drug is 
chiefly on the spinal cord and motor nerves. Thus, after toxic 
doses, there is a loss of reflex excitability with cessation of vol- 
untary movements lasting a day or two, then recovery with 
exaggerated reflexes and clonic convulsions. The primary effect 
is apparently due to paralysis of the motor nerve-endings, and 
the secondary effect to stimulation of the spinal cord. 

Under atropin the peripheral endings of the nerves in the 
unstriped muscle of the bronchioles, stomach, intestines, uterus, 



BELLADONNA. *]>] 

and bladder are all depressed. The motor nerve-endings in the 
voluntary muscles are depressed in frogs, but not perceptibly 
in man. The terminations of the sensory nerves are depressed 
by local applications of the drug, but not when it is given 
internally. 

Secretory Glands. — By depressing the nerve-endings in the 
secretory glands, atropin lessens nearly all the secretions — 
saliva, mucus, sweat, gastric juice, and milk. The pancreatic 
secretion and urine are not much affected, as the pancreas and 
kidneys are only partially controlled by the nerves. 

Alimentary Canal. — Atropin diminishes the total quantity 
of gastric juice and also the percentage of hydrochloric acid. 
Large doses decrease intestinal peristalsis, while small doses 
apparently increase it. Given with purgatives it prevents 
griping, but the manner of its action is not known. 

Temperature. — Large doses often cause a marked rise of tem- 
perature, probably by acting directly on the thermogenic centers. 

Eye. — Atropin dilates the pupil by paralyzing the oculo- 
motor nerve-endings in the sphincter muscle of the iris, and 
destroys the power of accommodation by paralyzing the nerve- 
endings in the ciliary muscle. Like other mydriatics, it also 
raises the intra-ocular pressure. These effects of the drug in 
the eye are best seen after its local application. 

Elimination. — Atropin is excreted chiefly by the kidneys, 
though much of it undergoes oxidation in the tissues. 

Toxicology. — The characteristic phenomena of belladonna- 
poisoning are dryness of the throat, dilated pupils, rapid pulse, 
hurried respiration, restlessness, talkative delirium, an erythe- 
matous rash, and, finally, stupor, paralysis, and collapse. 

The urine of patients suffering from belladonna-poisoning 
when dropped into the eye of an animal (except birds) causes 
dilatation of the pupil. 

Treatment of Poisoning". — After evacuating the stomach, 
tannic acid should be administered as a chemical antidote. 
Respiratory and circulatory stimulants are frequently required. 
Opium, physostigma, and jaborandi are somewhat antagonistic 
to belladonna, and, therefore, have been recommended as 
physiologic antidotes. Considerable caution should be exer- 
cised in their employment. 

Therapeutics. — Belladonna is employed chiefly to relax 
spasm, to check excessive secretion, to stimulate the vaso- 
motor center, to dilate the pupil, and paralyze accommodation, 
to allay peripheral irritation, to stimulate intestinal peristalsis, 
to impress the nervous mechanism of the heart, and to antag- 
onize certain poisons. 



7S CEREBRAL EXCITANTS. 

To Relax Spasm. — It is of little value in general convul- 
sions of cerebral or spinal origin, but it is of great service 
in local spasms excited by peripheral irritation. Thus, it is 
useful in whooping-cough and laryngismus stridulus. In the 
various forms of colic — renal, biliary, and intestinal — atropin 
is a valuable adjuvant to morphin, and should be given 
freely to guard the latter and to relax spasm. In asthma it 
may be given internally, but inhalation of the smoke made 
by burning the leaves often gives better results. When in- 
continence of urine is due to vesical hyperesthesia and spasm 
of the sphincter, as it frequently is in children, belladonna is 
a very reliable remedy. To be effective, however, the remedy 
must be pushed to the point of intolerance, that is, until it 
causes dryness of the throat and dilatation of the pupils. In 
obstinate torticollis or wry-neck intramuscular injections of 
atropin are often followed promptly by relief. In spasm of 
the anal sphincter and in dysmenorrhea suppositories of bella- 
donna are often efficacious. 

To Check Excessive Secretion. — Atropin is one of the 
best remedies we possess for controlling the night sweats of 
phthisis. A dose of 2 ^ Q 1 ^ gr. (0.0003 2-0.00065 gm.) at 
bedtime is sufficient. Unfortunately, untoward effects — dry- 
ness of the throat, thirst, and dimness of vision — often militate 
against its use. In salivation from mercury it is also useful. 
In hyperidrosis of the hands and feet belladonna is used both 
as an internal remedy and as a local application. When the 
mother is unable to suckle her child and the breast becomes 
swollen and tender, the thorough application of an ointment 
of belladonna will often serve to arrest the secretion of milk 
and to prevent suppuration, even though the latter seems 
imminent. In leucorrhea with ulceration of the os uteri, Trous- 
seau's suppositories containing 1 gr. (0.06 gm.) of the extract 
and 8 gr. (0.5 gm.) of tannin will be found beneficial. 

In the bronchopneumonia of childhood belladonna in large 
doses (2 drops of the tincture every hour) is often of the 
utmost value in lessening secretion and in relieving dyspnea. 
In pneumonia with edema it is also useful. 

To Stimulate the Vasomotor Center. — In shock and col- 
lapse atropin hypodermically is useful, though much less effective 
than adrenalin intravenously. It has also been recommended 
as a vasomotor stimulant in the algid stage of cholera. 

To Dilate the Pupil and Paralyze Accommodation. — If a 
drop or two of a solution of atropin, having the strength of 4 
gr. (0.26 gm.) to the ounce (30.0 c.c), be dropped into the con- 
junctival sac, dilatation of the pupil begins in a few minutes, and 



BELLADONNA. 79 

attains its maximum in about half an hour. Accommodation 
is not affected quite so quickly, paralysis not being complete 
within an hour and a half. On the other hand, mydriasis per- 
sists somewhat longer than the suspension of accommodation. 
The effect of a 4-grain solution usually lasts from ten days to 
two weeks. 

Atropin may be employed as a mydriatic to facilitate ophthal- 
moscopic examination, but euphthalmin, cocain, or homatropin 
should be given the preference, since the action of these drugs 
is much less persistent. In estimating errors of refraction it is 
necessary to select a mydriatic that will suspend the accom- 
modation, and for this purpose atropin may be used, although 
there are cycloplegics equally efficient and less persistent in 
their effects. In iritis it is indispensable in preventing and in 
breaking up adhesions between the iris and the capsule of the 
lens. In acute keratitis it is also very useful in allaying the 
ciliary irritation. 

The sulphate, on account of its ready solubility, is the salt 
usually selected. As a simple mydriatic \ gr. (0.016 gm.) to 
the ounce (30.0 c.c.) is sufficient, and the mydriasis from this 
solution will not last more than four or five days. As a 
cycloplegic in refraction work a strength of 4 gr. (0.26 gm.) 
to the ounce (30.0 c.c.) should be employed. A like solution 
is generally used in iritis. In keratitis a solution containing 
1-2 gr. (0.065-0.13 gm.) to the ounce (30.0 c.c.) will be effec- 
tive. 

To Allay Peripheral Irritation. — In the form of an oint- 
ment or plaster belladonna makes a very useful sedative appli- 
cation in muscular rheumatism (pleurodynia, wry-neck, lum- 
bago), in inflammatory affections of the joints, orchitis, and 
chronic heart-disease. 

Suppositories containing the extract are much used in pain- 
ful hemorrhoids, and for the relief of painfid defecation due to 
inflammation of the pelvic organs. 

To Stimulate Intestinal Peristalsis. — Belladonna is a use- 
ful adjuvant to other drugs in chronic constipation. By allay- 
ing spasm of the intestinal muscles it also prevents griping. 

To Impress the Nervous Mechanism of the Heart. — 
Although the manner of its action is obscure, belladonna is 
often efficacious in nervous palpitation and tachycardia. It may 
be applied over the region of the heart in the form of a large 
plaster, or given internally, alone or in combination with 
sodium bromid. In some cases of exophthalmic goiter, when 
given in doses large enough to cause some dryness of the 
throat, it is more useful than any other drug. For the purpose 



80 CEREBRAL EXCITANTS. 

of blocking inhibitory influences on the heart, Allbutt strongly 
advises the use of atropin hypodermically at the beginning of 
attacks of angina pectoris. 

To Antagonize Certain Poisons. — It is a useful antidote 
in poisoning by opium, physostigma, muscarin (poisonous prin- 
ciple of toadstools), hydrocyanic acid, aconite, jaborandi, and 
chloroform. 

Administration. — The root and leaves are not used inter- 
nally. The tincture is the most reliable of the liquid prepara- 
tions. For subcutaneous administration the sulphate of atropin 
should be employed, since atropin is only sparingly soluble in 
water. Children are relatively less susceptible to belladonna 
than adults, and, therefore, often tolerate much larger doses 
than their age would naturally indicate. The following for- 
mulae will serve to illustrate the manner of prescribing the 
drug: 

R Atropinae sulphatis, gr. j (0.065 g m -) > 

Acidi borici, gr. x (0.65 gm.); 

Aquae destillatae, f!|j (30.0 c.c). — M. 

Sig. A drop or two to be instilled into the conjunctivae twice a day. [Acute 
keratitis.) 

R Tincturae belladonnae, f^iss (5.5 c.c); 

Glycerini, f£ij (7.4 c.c.) ; 

Aquae menthae piperitae, q. s. ad f^ij (60.0 c.c). — M. 
Sig. Thirty minims three times a day for a child of three years. The dose to be 
gradually increased until slight flushing of the face is induced. ( Whooping-cough.) 

R Extracti belladonnae, gr. x (0.65 gm.' 

Acidi tannici, gr. vj (0.4 gm. 

Hydrargyri chloridi mitis, gr. xxx (2.0 gm.) ; 

Cocainae gr. vj (0.4 gm.); 

Unguenti petrolati, ^j (31.0 gm.). — M- 

Sig. Apply night and morning after washing the parts. [Hemorrhoids.) 

Ineompatibles. — Atropin should not be prescribed in 
solutions containing caustic alkalies or tannic acid. 

STRAMONIUM. 

(Jamestown Weed; Thorn-apple.) 

The drug is official as the leaves of Datura Stramonium, 2l 
weed growing in waste places in Europe, Asia, and America. It 
contains atropin, hyoscyamin, and a minute quantity of hyoscin. 

Preparations. Dose. 

Tinctura Stramonii, U. S. P 10-20 min. (0.6-1. c.c). 

Fluidextractum Stramonii, U. S. P 1-3 min. (0.06-0.2 c.c). 

Ex tractum Stramonii, U. S. P *-| gr. (0.015-0.03 gm.). 

Unguentum Stramonii, U. S. P., contains 10 per cent, of the extract. 



HYOSCYAMUS, 8 1 

Therapeutics. — Stramonium is a therapeutic equivalent 
of belladonna, and may be employed in the same class of 
diseases in which the latter is prescribed. It has a special 
reputation in asthma, in which disease it may be used in the 
form of cigarettes made of the dried leaves. Ointment of 
stramonium with an equal amount of ointment of galls makes 
a useful application for hemorrhoids. 

HYOSCYAMUS, U. S. P. 

(Henbane.) 

The leaves and flowering tops of Hyoscyamus niger, a plant 
growing in Europe, Asia, and North America. They contain 
hyoscyamin and hyoscin, and a small quantity of atropin. 

Preparations. Dose. 

Tinctura Hyoscyami, U. S. P 20-60 min. ( 1. 2-3.7 c.c). 

Fluidextractum Hyoscyami, U. S. P. . . . 5-20 min. (0.3-1.2 c.c). 
Extraction Hyoscyami, U. S. P ^-3 gr. (0.03-0.2 gm.). 

Physiologic Action. — In full doses hyoscyamus act£ 
like belladonna, causing dilatation of the pupils, dryness of 
the throat, and quickening of the pulse and respiration. On 
the brain its action is somewhat more sedative than that of 
belladonna. 

Therapeutics. — Like belladonna, it is used to relax spasm 
and to allay peripheral irritation. It may be employed in 
whooping-cough, m bronchitis with harassing cough, when opium 
is contraindicated, and in incontinence of urine due to vesical irri- 
tation. It is also a useful vesical sedative in acute cystitis. 

SCOPOLA, U. S. P. 

Scopola is the dried rhizome of Scopola carniolica, a peren- 
nial plant growing in southern Europe. It is closely related 
to belladonna and hyoscyamus. It contains several alkaloids, 
the chief of which are hyoscyamin and scopolamin. Scopolamin 
appears to be identical with hyoscin, and is official in the form 
of the hydrobromid {Scopolamines hydrobromidum). 

Preparations. Dose. 

Fluidextractum Scopolae, U. S. P 1-3 min. (0.06-0.2 c.c). 

Extractum Scopolse, U. S. P \-\ gr. (0.008-0.016 gm.). 

Physiologic Action and Therapeutics.— Scopola close- 
ly resembles hyoscyamus in its action, and may be used for 
the same purposes. 

Injections of scopolamin and morphin have been used to 



82 CEREBRAL EXCITANTS. 

some extent as a means of inducing general anesthesia. Korff, 
an ardent advocate of the method, makes three injections — 
the first 2 J hours, the second I \ hours, and the third \ hour 
before the operation, using in all -^ gr. (o.ooi gm.) of sco- 
polamin and \ gr. (0.02 gm.) of morphin. The advantages of 
the method are said to be the absence of mental excitement, 
bronchial irritation, and vomiting. As scopolamin and mor- 
phin, however, are not, as was formerly supposed, antagonistic 
in their action on respiration, considerable caution should be 
exercised in using them thus conjointly in such large doses. 

HYOSCYAMINA. 

Hyoscyamin is official in the form of the sulphate (Hyos- 
cy amines sulphas) and the hydrobromid (Hyoscyaminee hydro- 
bromidum), both of which are freely soluble in water. The 
dose of either salt is from j^-q— ^5 g r - (0.0004-0.0008 gm.). 
Hyoscyamin has an action almost identical in kind with that 
of atropin, though it depresses more powerfully than the latter 
the nerve-endings in the secretory glands, eye, etc. In pain- 
ful facial spasm and torticollis it is sometimes very useful. 
Dana has recommended it in the chorea of childhood. It may 
afford relief in the tremors of paralysis agitans, disseminated 
sclerosis, and chronic mercurial poisoning. 

HYOSCINA. 

Hyoscin itself is a colorless syrupy liquid, but its salts are 
solid and crystalline. Of the latter the hydrobromid (Hyos- 
cincE hydrobromidmn) is official, and may be given in doses of 
1 5 ■ ■ 7^ gr. (0.0004-0.0008 gm.). Hyoscin depresses the ter- 
minations of the same nerves as atropin. Its action in this 
respect, however, is more prompt and powerful than that of 
atropin, and its effect less persistent. Unlike atropin, it depresses 
the cerebrum almost from the beginning, a dose of y^ gr. 
(0.0005 gm.) usually being sufficient to induce sleep without 
causing a preliminary stage of excitement. It also differs from 
atropin in not stimulating, but rather depressing, the respiratory 
and vasomotor centers in the medulla. In large doses it has a 
tendency to produce paresis of the throat muscles, and for this 
reason is contraindicated in affections involving the throat, like 
diphtheria and scarlet fever. Toxic doses induce dryness of 
the throat, dilatation of the pupils, stupor, coma, extreme slow- 
ing of the respirations and pulse, and muscular relaxation. In 
animals death results from asphyxia. 

On account of the very pronounced susceptibility of certain 
persons to the action of hyoscin, the initial dose should always 
be small. 



COCA. 83 

Therapeutics. — Hyoscin hydrobromid is used as a somni- 
facient, a depressomotor, and an anaphrodisiac. It is a very 
efficient somnifacient in insomnia, associated with great mental 
or emotional excitement ; thus it often acts admirably in mania, 
delirium tremens, melancholia agitata, and typhoid fever with 
active delirium. As it has little effect upon the circulation, it 
sometimes acts favorably as a somnifacient in chronic heart 
disease, but usually it is inferior to morphin. Given hypo- 
dermically in doses of -jJo" S r - (0.0003 §" m twice daily, gradu- 
ally increased, it is sometimes useful in quieting the violent 
movements of acute chorea. It is the best remedy that we 
have in diminishing the severity of the tremors and in allaying 
the restlessnes of paralysis agitans. A dose of y-l-g- gr. (0.OOO4 
gm.), gradually increased to -^ gr. (0.0008 gm.), may be given 
in chloroform-water two or three times a day. It is an excel- 
lent remedy in spermatorrhea, erotomania, and allied sexual 
disorders. 

Administration. — It may be given hypodermically, or by 
the mouth in pills, granules, or aqueous solution. 

COCA, U. S. P. 

The leaves of Erythroxylon Coca, a native of Peru and other 
South American States. It contains several alkaloids, the 
most important being cocain, which is official as Cocai?ia, and 
Cocaines hydrochloridum. Both the free alkaloid and the salt 
appear in the form of colorless prismatic crystals, having a 
slightly bitter taste, and producing on the tongue a tempo- 
rary numbness. Cocain is sparingly soluble in water ( 1 : 600 
parts), much more so in alcohol (1 15), in ether (1 : 3.8), and 
olive oil (1 : 12) ; cocain hydrochlorid is freely soluble in water 
(1 : 0.4 parts), somewhat less so in alcohol (1 : 2.6), and insol- 
uble in ether and oils. The dose of either cocain or its salt is 
from J— 1 gr. (0.015-0.06 gm.). Cocain to the amount of 
5 per cent, is contained in the newly introduced oleate of coca 
{Oleatum cocaines). 

Preparations. Dose. 

Fluidextractum Cocae, U. S. P. ..... £-2 fl. dr. (2.0-8.0 c.c). 

Vinum Cocae, U. S. P 2-8 fl. dr. (8.0-30.0 c.c). 

Physiologic Action. — In full doses cocain raises the arte- 
rial pressure and increases the rate of the pulse. The rise of 
arterial pressure is due to stimulation of the vasomotor center 
and acceleration of the heart, and, perhaps, also, to constric- 
tion of the vessels from a peripheral action. The increased 



84 CEREBRAL EXCITANTS. 

pulse-rate is probably due to stimulation of the accelerator 
mechanism and depression of the vagal endings. After very 
large doses there is a pronounced fall of the arterial pressure 
from paralysis of the heart and vasomotor center. 

Locally, it is a powerful vasoconstrictor; the ischemia, how- 
ever, is finally replaced by congestion. 

Central Nervous System. — Cocain first stimulates and 
then depresses the central nervous system — brain, medulla, and 
spinal cord. Both the psychic and motor areas of the brain 
are affected, large doses first inducing wakefulness, mental 
exhilaration, physical unrest, and then more or less depression. 
Toxic doses not rarely cause clonic convulsions of cerebral 
origin. The injection of a small quantity into the spinal canal 
is followed in a few minutes by complete anesthesia of the 
entire lower half of the body, without any disturbance of 
consciousness. 

Respiratory System. — In small doses it increases both the 
depth and the rate of the respirations by stimulating the res- 
piratory center. Toxic doses render the respiratory move- 
ments irregular in rhythm and shallow, and finally kill through 
asphyxia. 

Muscles. — It appears first to stimulate and then to paralyze 
striated muscles. 

Kidneys. — Cocain has very little influence on the excretion 
of urine. The nitrogenous elimination is probably slightly 
decreased. 

Alimentary Canal. — Small doses increase and large doses 
diminish peristaltic movement. 

Temperature. — Therapeutic doses are without effect, but 
toxic doses cause a rise of temperature, probably by increas- 
ing heat production. 

Local Action. — A very important physiologic property of 
cocain is its power, when applied directly to a mucous mem- 
brane or an abraded surface, or when injected under the skin, 
of inducing temporary anesthesia of the part by paralyzing 
the sensory nerve-filaments. The anesthesia begins in from 
five to ten minutes, and generally lasts from twenty to thirty 
minutes. The application of cocain solutions directly to cuta- 
neous surfaces is without effect, since absorption through the 
epidermis is very slight. In addition to anesthesia, cocain 
causes a blanching of the part, which is subsequently followed 
by congestion. Applied in sufficient concentration, it is a 
general protoplasmic poison, nerve-tissue being especially sensi- 
tive to its influence. 

Bye. — The instillation into the eye of a few drops of a 4 



COCA. 85 

per cent, solution of cocain hydrochlorid causes in from ten to 
fifteen minutes, in addition to anesthesia, contraction of the 
conjunctival vessels and moderate dilatation of the pupil. The 
mydriasis attains its maximum in about an hour, and persists 
for from twelve to fifteen hours. It is of peripheral origin, and 
is probably caused by stimulation of the sympathetic nerve- 
endings. Cocain has but little effect on accommodation. 
Strong solutions have an injurious effect upon the corneal 
epithelium. 

Toxicology. — The symptoms of acute cocain-poisoning are 
somewhat variable ; the usual phenomena, however, are nerv- 
ous excitement, followed by delirium, and ultimately by 
stupor ; nausea, vomiting, a very rapid pulse, hurried respira- 
tions, elevation of temperature, dilatation of the pupils, and 
convulsive seizures. 

The treatment is purely symptomatic. When there are- 
symptoms of circulatory and respiratory failure, ammonia, 
atropin, and strychnin are indicated. When cerebral excite- 
ment and convulsions are prominent features, inhalations of 
chloroform may be employed, and bromids and chloral may 
be administered tentatively. 

Untoward Effects of Medicinal Doses. — There is a very 
wide variation in individual susceptibility to cocain. In some 
subjects the local application of the drug to the nose or throat, 
even in solutions of moderate strength, is followed by nausea, 
vomiting, blindness, syncope, or convulsions. 

Chronic Poisoning" {Cocainism). — A potent cause of the 
cocain-habit has been the frequent use of the drug in diseases 
of the nose and throat. Tyson states that he has known three 
successive chiefs of clinic in nose and throat dispensary service 
to acquire the habit. The habit is also common among those 
addicted to other narcotics, such as opium, alcohol, and 
chloral. The chief symptoms are emotional excitement, 
physical unrest, mental impairment, moral turpitude, halluci- 
nations, mild epileptiform attacks, dilatation of the pupils, a 
rapid, feeble pulse, severe gastric disturbance, wasting, and 
anemia. When cocainism is uncomplicated the prognosis 
is guardedly favorable. The drug should be withdrawn 
rapidly but not suddenly. Treatment in a sanatorium is always 
advisable. Stimulants like strychnin are often useful. Hygienic 
and dietetic measures calculated to improve general nutrition 
are indicated. 

Therapeutics. — Cocain is employed as a local anesthetic, 
mydriatic, and respiratory and circulatory stimulant. 

As a Local Anesthetic. — As a local anesthetic cocain has a 



86 CEREBRAL EXCITANTS. 

very wide range of usefulness. In the various operations on 
the eye, nose, throat, urethra, and rectum it is indispensable. 
In minor surgical operations — like amputation of the fingers, 
removal of small neoplasms, opening of small abscesses — it 
may also be employed with advantage. In these cases care 
must be taken to prevent undue absorption of the drug, and 
this is best accomplished by the application of a tight rubber 
band to the proximal side of the part to be operated on, thus 
controlling the circulation. A 2 per cent, solution may be 
injected to the extent of a dram with safety. The capillary 
oozing should not be checked immediately, as it serves to carry 
off the cocain. The same quantity of cocain in weak solution 
is distinctly less toxic than it is when in strong solution (Custer). 
In operations in which the circulation cannot be controlled, 
and in which much of the solution must be allowed to remain 
in the tissues, the method employed by Schleich, known as 
infiltration anesthesia, is of very great value. Schleich employs 
solutions of three strengths. The one of medium strength con- 
sisting of — 

Cocain hydrochloric!, I gr. (0.065 gm.) ; 

Morphin hydrochloric!, \ gr. (0.013 gm.) ; 

Sodium chlorid, 2 gr. (0.13 gm.) ; 

Sterilized, distilled water, 2 fl. oz. (60.0 c.c). 

The stronger solution contains 2 gr. (0.13 gm.) of cocain, 
and the weaker solution, -^ gr. (0.0065 gm.). 

The important factors in the induction of anesthesia by this 
method are the ischemia of the tissues caused by the pressure 
of the injected fluid, the compression of the terminal nerve- 
filaments from the same cause, and the direct paralysis of the 
sensory nerves by the cocain. The effect of the morphin is 
not local, but general. Physiologic salt-solution is employed 
as the vehicle, because it is unirritating to the tissues. 

The field of operation may be infiltrated en masse, or it may 
be surrounded by an anesthetic edematous zone. In addition, 
the nerves leading to the part may also be cocainized either 
some distance from the prospective incision, or directly as they 
are exposed in the wound. 

An ordinary antitoxin syringe capable of holding at least 
10 c.c. may be employed. The derm should be infiltrated 
before the deeper tissues are injected. The needle having been 
introduced obliquely, a few drops of the solution are forced 
out ; the needle is then thrust deeper and deeper, while more 
of the fluid is injected in various directions until the field is 
thoroughly edematized. The subsequent application of an 
ice-bag to the part will intensify the analgesic effect of the 



COCA. 8? 

injection. At least five minutes should elapse after the infil- 
tration before the incision is made. The period of analgesia 
generally lasts from twenty to thirty minutes. The strength 
of the solution and the amount employed will depend upon 
the sensitiveness of the part, the extent of the operation, and 
the amount of cocain that is likely to be retained in the tissues. 
It is not safe to allow more than I grain of cocain to remain 
in the part. Of the strong solution, i ounce (30.0 c.c.) ; of the 
solution of medium strength, 2 ounces (60.0 c.c.) ; and of the 
weak solution, 10 ounces (300.0 c.c.) or more may be em- 
ployed without risk. 

Medullary Cocainization. — The employment of spinal sub- 
arachnoid injections for the purpose of inducing analgesia 
was suggested by Corning in 1885, and made practical by 
the researches of Bier, published in 1899. The technic of 
medullary cocainization is as follows : The entire lumbar 
and sacral region is prepared with antiseptic care as for 
operation ; the patient is placed in a sitting posture, and the 
injection is made at the level of the crest of the ilium, that 
is, just above or below the fourth lumbar vertebra, and 1 
cm. Q- in.) external to its spinous process. The solution is 
injected through a fine iridoplatinum needle, about 9 cm. 
(3-4 in.) long, attached to an ordinary hypodermic syringe 
capable of holding 2 c.c. (30 min.). As the injection should 
not be made before a flow of cerebrospinal fluid is observed, 
the needle should be introduced into the subarachnoid space 
before the syringe is attached. The injection is made very 
slowly, and to insure the retention of the solution the needle 
is held in situ for about a minute, then carefully withdrawn, 
and the puncture sealed with collodion. A 2 per cent, solu- 
tion (9 gr.-i oz. — 0.6 gm-30.0 c.c.) of cocain hydrochlorid is 
usually employed ; it should be freshly prepared and sterile. 
From 15-20 min. (1.0-1.2 cc.) are injected. The amount of 
cocain should not exceed f gr. (0.025 gm.). Analgesia extend- 
ing downward from about the level of the diaphragm follows in 
from five to ten minutes, and usually persists about an hour 
and a half. 

The relative value of this method of inducing analgesia has 
not yet been determined; it is certainly not altogether free 
from danger. Unpleasant after-effects — fever, headache, ver- 
tigo, nausea, and vomiting — are of frequent occurrence. Co- 
cain analgesia is not suitable for prolonged, complicated opera- 
tions, especially when they are intra-abdominal ; and since it 
does not induce unconsciousness, it should not be employed 
in young children nor in insane or hysteric adults. 



88 CEREBRAL EXCITANTS. 

In inflammations and ulcerations of the nose, pharynx, and 
larynx cocain may be employed alone or in combination with 
antiseptic sprays or powders. In acute coryza and hay-fever 
it gives great relief by lessening the sensibility and constricting 
the turgid tissues. 

In laryngeal tuberculosis it is invaluable for the relief of the 
intense pain and dysphagia. It may be given in insufflation 
in combination with iodoform, iodol, or morphin. As a local 
anesthetic it is also used internally to relieve the pain of gas- 
tric ulcer and to check excessive vomiting. 

The application of a 10 per cent, solution of cocain hydro- 
chlorid on a cotton pledget has been found useful in rigidity 
of the os uteri. 

As a Mydriatic. — As a mydriatic, cocain is not so gen- 
erally useful as atropin. Since, however, it only slightly 
impairs accommodation, and its effects pass off in a few hours, 
it is a convenient mydriatic for retinal examinations. In iritis 
atropin is distinctly preferable on account of its forcible action 
and lasting effect. The mydriatic effect of cocain is readily 
neutralized by the instillation into the eye of a few drops of a 
\ per cent, solution of eserin. 

As a Respiratory Stimulant. — Cocain is an active respira- 
tory stimulant, and for this reason, and also on account of its 
general excitant influence, it is a useful physiologic antidote in 
opium- poisoning. 

As a Circulatory Stimulant. — In adynamic pneumonia, 
cocain, administered hypodermically, is an efficient adjuvant to 
strychnin. 

Administration. — As a local anesthetic to mucous mem- 
branes the hydrochlorid is employed in solutions varying in 
strength from 2 to 20 per cent. The mucous membrane of 
the larynx is less susceptible than that of the nose or throat. 
On the latter, from 4 to 6 per cent, solutions are usually suffi- 
cient. A solution stronger than 4 per cent, should not be used 
in the eye on account of the danger of inducing degenerative 
changes in the corneal epithelium. 

Aqueous solutions of cocain lose in efficacy on boiling, 
methyl alcohol and benzoic acid being split off from the 
alkaloid. 

The drug is not well borne by children and women of a 
neurotic temperament. The danger of causing the habit 
from the frequent use of cocain in chronic diseases of the 
nose and throat must never be lost sight of, and under no 
circumstances should the remedy be placed in the patient's 
own hands. In tuberculous laryngitis with dysphagia small 



CEREBRAL DEPRESSANTS. 89 

tablets containing from -^o-jj g r - (0.003-0.005 gm.) of cocain 
may be allowed to dissolve slowly in the mouth, or the drug 
may be used in the form of a powder or spray : 

R Cocainse hydrochloride gr. xx (1.3 gm.) ; 

Resorcinol, gr. x (0.65 gm. ); 

Aquae, f^j (30.0 c.c.) — M. 

Sig. To be used as a spray. ( Tuberculous laryngitis.) 

The fluidextract and the wine of coca are used as mild 
stimulants. 

Incompatibles. — Cocain is incompatible with tannic acid, 
alkaline carbonates, iodids, borax, and zinc sulphate. It cannot 
be added to Dobell's solution, since the latter contains borax. 



CEREBRAL DEPRESSANTS. 

The cerebral depressants may be classed as somnifacients, 
general anesthetics, general analgesics, and anticonvulsants. 

Somnifacients or hypnotics are remedies which induce sleep. 
The factors favoring natural sleep are the withdrawal of 
afferent stimuli, decreased responsiveness of the brain-cells as 
the result of fatigue, the accumulation in the blood of products 
evolved by the cells in the exercise of their functions, and, 
finally, lessening of the blood-supply to the brain. Pure som- 
nifacients inhibit the functional activity of the brain-cells, but 
they do not completely suspend the power of the cells to 
recuperate (the main object of sleep) nor to react to stimuli 
which reach them from without. 

General anesthetics are drugs which induce unconscious- 
ness and insensibility. Their effect upon the brain-cells is 
much more profound than that of the hypnotics, in that they 
temporarily inhibit the responsiveness of the cells to external 
stimuli, and suspend more or less completely recuperative 
changes. 

General a7ialgesics or anodynes are remedies which relieve 
pain. They may act either by directly influencing the receptive 
centers in the brain or by preventing the transmission of 
painful impressions through the sensory nerves and spinal 
cord to the brain. 

Anticonvulsants are remedies which check excessive motor 
activity. In the case of cerebral convulsions they may act 
by directly depressing the cells in the cortex of the brain, by 



go SOMNIFACIENTS. 

lessening the power of the sensory tract in the peripheral 
nerves and spinal cord to transmit to the brain-cells stimuli 
from without, or by lessening the power of the motor tract in 
the spinal cord and peripheral nerves to transmit to the mus- 
cles the excessive discharges emanating from the brain-cells. 

SOMNIFACIENTS. 

The most important element in the treatment of insomnia 
is the removal of the cause. A potent factor in many cases of 
persistent insomnia is the circulation in the blood of the prod- 
ucts of faulty metabolism, as seen in dyspeptic and gouty 
subjects. In such affections a careful regulation of the diet is 
of the utmost importance. The evening meal especially should 
be simple and light. Systematic exercise, coupled with the 
use of mild mercurial or saline aperients, often proves more 
effective in promoting sleep than the exhibition of hypnotics. 
In the aged insomnia is very often associated with lowered vas- 
cular tone, and when such is the case, small doses of strychnin 
are beneficial. In chronic valvular disease stimulants like 
digitalis, strophanthus, and nux vomica are indicated. In 
chronic Bright's disease insomnia is a common symptom, and 
it may depend upon the retention in the blood of excrementi- 
tious materials or it may be due to high arterial tension. In 
the former case a milk-diet and the use of eliminants will be 
most helpful, and in the latter case the administration of some 
vasodilator, such as nitroglycerin or erythrol tetranitrate, will 
often afford marked relief. Tea, coffee, and tobacco are some- 
times preventives of sleep, and if so they must be used sparingly 
or perhaps altogether avoided. When anemia is a causal factor, 
iron and arsenic will be needed. Insomnia from overwork, 
mental anxiety, or grief will demand mental rest, diversion, or 
change of scene. 

When the habit of sleeplessness has become well established 
it may require more than the removal of the cause to effect a 
complete cure. Simple measures, however, should always be 
tried first before resorting to hypnotics. The bedroom should 
be quiet, well ventilated, and of moderate temperature. When 
the feet are cold the blood should be diverted from the head 
by hot foot-baths, which may be made more effective by the 
addition of mustard. Vigorous rubbing of the limbs is also 
useful. A glass of hot milk, a cup of bouillon, or a toddy just 
before retiring often acts favorably as a derivative. In some 
persons light reading for half an hour, in others a brisk walk, 
will invite sleep. In neurasthenia, massage and the systematic 
use of the wet-pack are invaluable aids. 



OPIUM. , 91 

Hypnotic drugs must be used with caution. Their con- 
tinued exhibition predisposes to invalidism and favors the 
development of vicious habits. In simple habitual insomnia 
they should not be prescribed until general measures have 
been tried and found wanting. 

The chief somnifacients are : 

Opium. Sulphonal. 

Cannabis indica. Trional. 

Hyoscin. Paraldehyd. 

Hydrated chloral. Urethan. 

Chloralformamid (chloralamid). Hedonal. 

Chloralose. Veronal. 

Chloretone. Bromids. 

OPIUM, U.S. P. 

Opium is the inspissated juice obtained by incising the unripe 
capsules of Papaver somniferum, a poppy indigenous in West- 
ern Asia. To be up to the official standard, it should contain 
not less than 9 per cent, of crystallized morphin. It appears 
in the form of irregular lumps, having a dark-brown color, a 
gummy consistence, a peculiar narcotic odor, and a bitter taste. 
In addition to meconic acid and a neutral principle, mecojiin, it 
contains a number of alkaloids, the most important of which 
are morphin, codein, thebain, papavetin, narcotin, and narcein. 

Preparations. Dose. 

Opium, U. S. P. (9 per cent, of morphin) . . \-2. gr. (0.03-0.13 gm.). 

Opii Pulvis, U. S. P. (1 2-1 2. 5 per cent, of 

morphin) \-z gr. (0.03-0.13 gm.). 

Opium Deodoratum, U. S. P. (denarcotized 

opium, 12-12. 5 per cent, of morphin) . . . i-2 gr (0.03-0.13 gm.). 

Opium Granulatum, U. S. P. (12-12.5 per 

cent, of morphin) ^-2 gr. (0.03-0.13 gm.). 

Pilulse Opii, U. S. P. (1 gr. — 0.06 gm. of pow- 
dered opium in each) 1-2 pills. 

Extractum Opii, U. S. P. (20 per cent, of 

morphin) ^-1 gr. (0.016-0.65 gm.). 

Tinctura Opii, U. S. P. (laudanum ; 10 per 
cent, of granulated opium ; 100 c.c, contain 
1.2 to 1.25 gm. of morphin) 5-20 min. (0.3-1.2 c.c). 

Tinctura Opii Deodorati, U. S. P. (10 per 
cent, of granulated opium ; 100 c.c, contain 
1.2 to I.25 gm. of morphin) 5-20 min. (0.3-1.2 c.c). 

Tinctura Opii Camphorata, U. S. P. (pare- 
goric ; contains camphor, benzoic acid, oil 
of anise, and about 2 gr. — 0.12 gm. of pow- 
dered opium per ounce) \-\ fl. dr. ( 1. 8-1 5.0 c.c). 

Tinctura Ipecacuanhas et Opii, U. S. P. . . . 5-15 min. (0.3-1.0 c.c.) 

Acetum Opii, U. S. P. (black drop; 10 per 

cent, of powdered opium) 5-20 min. (0.3-1.2 c.c). 



92 SOMNIFACIENTS. 

Preparations. Dose. 

Vinum Opii, U. S. P. (io per cent, of granu- 
lated opium) 5-20 min. (0.3-1.2 c.c). 

Pulvis Ipecacuanhse et Opii, U. S. P. (Do- 
ver's powder; contains 10 per cent, of 
powdered opium ; 10 per cent, of ipecac ; 
and 80 per cent, of sugar of milk) . . . 5-10 gr. (0.3-0.6 gm.). 

Trochisci Glycyrrhizge et Opii, U. S. P. (each 
contains ^ gr. — 0.005 S m - °f powdered 
opium). 

Emplastrum Opii, U. S. P. (6 per cent, of 
extract of opium). 

Morphin is the chief alkaloid of opium and represents its 
physiologic activity. It occurs in white prismatic crystals, or 
fine needles, of a bitter taste, and very slightly soluble in 
water. The salts of morphin, being much more soluble than 
the alkaloid itself, are generally prescribed. 

The following alkaloids of opium and their preparations are 
used medicinally : 

Preparations. Dose. 

Morphina, U. S. P $-£ gr. (0.008-0.032 gm.). 

Morphinse Acetas, U. S. P Hg r ' (0.008-0.032 gm.). 

Morphinse Hydrochloridum, U. S. P |-| gr. (0.008-0.032 gm.). 

Morphinse Sulphas, U. S. P l~ J gr. (0.008-0.032 gm.). 

Pulvis Morphinae Compositus, U. S. P, (Tul- 

ly's powder; contains licorice, camphor, 

calcium carbonate, and morphin sulphate) 5-10 gr. (0.3-0.6 gm.). 

Codeina, U. S. P £-2 gr. (0.03-0.13 gm. V 

Codeinse Sulphas, U. S. P £-2 gr. (0.03-0.13 gm. J. 

Codienae Phosphas, U. S. P £-2 gr. (0.03-0.13 gm.). 

The following compounds are derived from the alkaloids 
of opium. From morphin : apomorphin (see p. 273), heroin, 
dionin, and peronin ; from codein : apocodein (see p. 274); and 
from narcotin : cotarnin hydrochlorid (see p. 380). 

Physiologic Action. — Nervous System. — In man the 
dominant action of opium is on the cerebrum. Even in small 
doses the drug diminishes all sensations, especially those of 
pain, and causes drowsiness. In full therapeutic doses it pro- 
duces natural sleep, from which the patient usually awakes 
refreshed, but not rarely complaining of dull headache and 
nausea. Toxic doses are followed by profound coma. In 
some instances the narcotic effect is preceded by a short period 
of exaltation or exhilaration, with increased play of the imagi- 
nation. This excitement, as in the case of alcohol, depends 
rather upon depression of the controlling centers than upon any 
direct stimulation of the psychic functions. Unlike chloral, 
opium has little action, except in large doses, on the motor 
cells of the brain cortex. 



opium. 93 

Opium increases to some extent the reflex irritability of the 
spinal cord. In human beings this action is rarely apparent, 
owing to the much greater sensitiveness of the brain to the 
influence of the drug, but in animals, like the frog, in which 
the cerebral hemispheres are poorly developed, large doses 
give rise to tetanic convulsions. In some of the opium alka- 
loids, particularly thebain and laudanin, the convulsant action 
is predominant. 

On the peripheral sensory and motor nerve-endings opium 
has little or no effect. 

Respiratory System. — Opium is a powerful depressant of 
the respiratory center in the medulla. In poisoning, the respi- 
rations become progressively weaker and fewer, and if the 
dose has been sufficiently large, finally cease entirely. 

Bye. — Applied to the conjunctiva, morphin has no effect 
upon the pupil, but when administered internally in toxic doses 
it causes extreme myosis through a central action. In fatal 
poisoning, dilatation of the pupil is observed just before death 
as a result of the asphyxia. 

Circulatory System. — Opium dilates the peripheral cuta- 
neous vessels and causes flushing, sweating, and occasionally 
itching; otherwise it has little effect on the circulation. In 
poisoning, the pulse at first is full and somewhat infrequent, 
and later it is feeble and frequent, but these changes are chiefly 
the result of the asphyxia. 

Secretions. — All the secretions, except the sweat, are dimin- 
ished by opium. 

Alimentary Ganal. — In man medicinal doses of opium 
lessen peristaltic movements, probably by depressing some 
part of the nervous mechanism in the bowel wall. To this 
action and the diminished intestinal secretion the well-known 
constipating effect of the drug is to be attributed. Very large 
amounts of morphin, especially if introduced directly into the 
blood, sometimes increase peristaltic movements and induce 
purgation, probably by depressing the inhibitory nerve of the 
bowel. 

Metabolism. — Morphin decreases to some extent the ab- 
sorption of oxygen and the excretion of carbonic acid. By 
interfering with respiration and oxidation it sometimes causes 
slight glycosuria. 

Elimination. — Morphin escapes from the body chiefly 
through the stomach and bowel, only minute quantities appear- 
ing in the urine. Elimination is rapid, and even after hypo- 
dermic injection the drug may be found in the stomach within 
a few minutes. Ordinarily only a small amount of the mor- 



94 SOMNIFACIENTS. 

phin injected is oxidized in the tissues, but under increasing 
doses the proportion is gradually increased, so that in habitues 
only traces appear in the excreta. 

Conditions Modifying the Action of Opium. — Cer- 
tain symptoms and diseases counteract the narcotic effect of 
opium, and when these are present the drug may be used in 
much larger doses than are generally prescribed; thus, patients 
suffering from diabetes or affections attended with severe pain, 
such as acute peritonitis, renal or biliary colic, can frequently 
take with advantage doses that under other circumstances 
would produce profound narcosis. On the other hand, when 
there are evidences of nephritis the drug must be used with 
great caution, since small doses not infrequently produce lethal 
effects. 

Age and sex modify its action. Children, on account of 
the sensitiveness of their nervous systems, are peculiarly sus- 
ceptible to opium, so that it must be given in smaller doses 
than the age would naturally indicate. A drop of laudanum 
has produced a fatal result in a child less than six months 
old. Its action is more pronounced on women than on men, 
and in the former it is more apt to cause disagreeable after- 
effects. 

Patients rapidly acquire a tolerance of the drug through 
frequent repetition of the dose, so that habitues can often take 
enormous amounts without experiencing the usual effects. 

The Action of Opium and Morphin Compared. — 
Apart from being more powerful than opium, morphin differs 
from the latter in having a less constipating, less nauseating, 
and less diaphoretic effect. 

Toxicology. — Acute Opium-poisoning-. — Unless the dose 
is very large, there may be at first a stage of excitement, in 
which the imagination is stimulated and the feelings are ex- 
alted. This stage is soon followed by one of depression, in 
which the patient becomes listless and drowsy, and finally falls 
into a deep sleep. The pulse is slow and full, the pupils are 
contracted to a pin-point size, the respirations are slow and 
labored, the muscles are relaxed, and the face is pale. In this 
stage it is still possible to arouse the patient by loud noises, 
flagellation, or shaking. In the third stage coma is absolute, 
the pulse is rapid and irregular, the skin is clammy, and the 
breathing is shallow and irregular. Finally, death results 
from paralytic asphyxia. 

Treatment of Acute Opium-poisoning. — The stomach should 
be emptied by means of the stomach-pump or a stimulating 
emetic, such as zinc sulphate or mustard flour. Since mor- 



opium. 95 

phin is eliminated by the stomach and then reabsorbed, lavage 
should be repeated at short intervals. Black coffee may be 
given by the mouth or by the rectum ; it promotes wakeful- 
ness and also stimulates respiration. The best chemical anti- 
dote is potassium permanganate ; 3 to 5 grains (0.2-0.3 g m 
of this drug, dissolved in a glassful of water, should be given 
at once and repeated in thirty minutes. Tannic acid is also 
recommended as a chemical antidote. The best physiologic 
antidotes are the powerful respiratory stimulants, such as 
atropin, strychnin, and caffein ; one or all of these may be given 
hypodermically in full doses. 

Artificial respiration is of the greatest value, and should be 
maintained so long as the beating of the heart continues. It 
is necessary that the patient should be aroused and kept awake, 
so that he himself can aid in keeping up respiration. Flicking 
with a wet towel, the use alternately of hot and cold water, 
and the application of the faradic current are among the meas- 
ures that may be employed in staving off sleep. In carrying 
out the treatment it is important to avoid chilling or exhausting 
the patient. 

Chronic Poisoning" (Morphinomania, Morphinism). — The 
symptoms resulting from the habitual use of opium are an 
irresistable craving for the drug, loss of flesh and strength, 
tremors, anemia, a peculiar sallow complexion, anorexia, 
deranged digestion, a tendency to diarrhea, disturbed sleep, 
mental depression, irritability, and a characteristic propensity 
for lying and deceiving. 

Treatment of Chronic Opium-poisoning . — Isolation in a spe- 
cial institution or asylum is almost imperative. As a rule, the 
drug should be withdrawn rapidly, but in aggravated cases 
not too abruptly for fear of collapse. The diet should consist 
of nutritious, easily digested food. Strychnin, while it is with- 
out specific action, is often extremely valuable for its stimulating 
effect. Bromids and cannabis indica are sometimes useful in 
ameliorating the distress which follows the withdrawal of 
opium. Sulphonal, paraldehyd, and veronal are the best 
somnifacients. Massage, graduated exercise, and the Turkish 
bath are useful roborant measures in the convalescent stage. 

Therapeutics. — Opium is used to relieve pain and dis- 
tress ; to induce sleep ; to allay peripheral irritation ; to check 
excessive secretion ; to promote diaphoresis ; to eontrol con- 
vulsions ; and to check hemorrhage. 

To Relieve Pain and Distress. — Opium is by far the best 
analgesic that we possess. In allaying the severe pain of 
gross lesions — -fractures, malignant growths, and acute inflam- 



96 SOMNIFACIENTS. 

mation of serous membranes — it has no rival. In neuralgia 
and other forms of recurrent pain it should be used only 
after all other measures have failed, and then with extreme 
caution, since the danger of forming the opium-habit in these 
cases is very great. In the painful crises of locomotor ataxia 
its use may become imperative. Osier regards morphin, 
hypodermically, as the most useful drug in those attacks of 
angina pectoris in which amyl nitrite proves ineffective. 

In various forms of colic — renal, biliary, and intestinal — it is 
well to combine atropin with morphin, since the former aids 
the latter in relaxing the spasm. 

Acute inflammation of the brain and its membranes cannot 
be considered, as was formerly the case, a contraindication to 
the use of opium ; indeed, in cerebrospinal fever and other 
forms of acute meningitis it may be the only remedy that will 
afford relief from the intense suffering. In most cases of 
acute appendicitis morphin should be withheld, since it masks 
the symptoms and thus interferes with an accurate study of 
the local conditions. 

In acute melancholia and other psychoses associated with 
profound mental anxiety, opium often exerts an excellent 
calmative effect. In many cases of chronic heart-disease it is 
invaluable in relieving the general discomfort and in pro- 
moting sleep. To obtain the best results, however, it should 
be given hypodermically. 

To Induce Sleep. — While opium will relieve insomnia from 
almost any cause, it is especially suitable when the cause of 
the sleeplessness is pain. It is also useful as a somnifacient 
in continued fevers, like typhoid fever, in delirium tremens, 
and in chorea, when the movements prevent sleep, . 

Occasionally, owing to some peculiar idiosyncrasy, opium 
causes excitement and wakefulness instead of sleep. In states 
of extreme nervous excitement chloral is generally superior to 
opium, but not infrequently better results are obtained from a 
combination of opium with chloral than from either drug 
singly. 

To Allay Peripheral Irritation. — No remedy is so useful 
as opium or one of its derivatives in relieving the irritative 
cough of bronchitis and phthisis. It should not be employed, 
however, in pulmonary affections when the expectoration is 
copious, and in pulmonary edema it is a dangerous drug. In 
asthma morphin hypodermically, with or without atropin, is a 
reliable remedy. In some cases of acute vomiting injections 
of the drug act happily, but in the pernicious vomiting of preg- 
nancy its effects are not good. In chordee and in threatened 



opium. 97 

abortion is frequently employed in the form of suppositories, 
but it acts just as well when given by the mouth or hypo- 
dermically. 

To Check Excessive Secretion. — In acute inflammatory 
affections of the bowel, after irritating matters have been re- 
moved, opium is often serviceable in checking the excessive 
secretion. In cholera infantum hypodermic injections of mor- 
phin (j-J^ gr. — 0.00065 gm.) are sometimes of benefit. 

In diabetes mellitus it does mare good than any other 
remedy, and as the disease establishes a tolerance for the drug, 
it should be given in ascending doses until it induces favorable 
or untoward results. The manner in which it acts in this dis- 
ease is unknown. Codein is preferred by some practitioners 
to morphin and opium, since it causes less disagreeable after- 
effects. In diabetes insipidus the drug is of far less value. 

To Promote Diaphoresis. — In the beginning of " colds," 
and in so-called muscular rheumatism, it is useful for its sudo- 
rific effect. In these cases Dover's powder is the best prepa- 
ration, since the ipecac which it contains assists the opium in 
promoting diaphoresis. 

To Control Convulsions. — Morphin hypodermically is of 
service in controlling the painful spasmodic seizures of tetanus. 
Mackenzie, Loomis, and Osier speak favorably of its action 
in the convulsions and other nervous manifestations of uremia, 
and unquestionably it may be given with great benefit in many 
cases, but it should always be employed with considerable 
caution, especially when there are evidences of chronic inter- 
stitial nephritis. 

Flechsig's method of using opium in the treatment of 
epilepsy is occasionally of service in old and obstinate cases. 
This method consists in giving opium in large doses for a 
period of six weeks (beginning with 1 grain of the extract the 
dose is rapidly increased until 1 5 grains a day are taken at the 
end of the first week, this amount being kept up for six 
weeks). The opium is abruptly withdrawn and potassium 
bromid is substituted. Large closes of the latter drug (30 
grains three times a day) are given for about two months, and 
are then gradually reduced until less than 40 grains a day are 
being taken. 

To Check Hemorrhage. — It is a common practice to com- 
bine opium with hemostatics in the various hemorrhages, such 
as hemoptysis, hematemesis, and enter orrhagia. The good 
which it accomplishes is probably the result of its calmative 
influence on the nervous system. 

External Use. — In the form of a lotion it is extensively em- 
7 



98 SOMNIFACIENTS. 

ployed as a sedative application in sprains, bruises, articular 
rheumatism, and erysipelas, but any other weak alcoholic 
preparation would probably be quite as efficient, since opium 
itself has no effect on the sensory nerve-endings. In these 
cases, notwithstanding the chemical incompatibility of the two 
drugs, it is generally combined with lead subacetate, as in the 
following formula : 

}£ Tincturse opii, 

Liquoris plumbi subacetatis, aa ^ij ; 

Aquae, q. s. ad Oj. — M. 

Untoward Effects. — In some persons the use of opium, 
even in moderate doses, is followed by headache, depression, 
anorexia, nausea, and vomiting. In others, on account of a 
peculiar idiosyncrasy, it causes excitement and wakefulness 
instead of sleep. In rare instances it occasions general pru- 
ritus or an erythematous rash. 

Contraindications. — Opium should not be used in pulmo- 
nary affections associated with embarrassed respiration, such 
as edema, and pneumonia during the stage of consolidation. 
For reasons already mentioned it is best to withhold it in ap- 
pendicitis. When chronic nephritis exists it must be used 
with the utmost circumspection. 

Administration. — When a prompt analgesic effect is de- 
sired, one of the salts of morphin should be selected in prefer- 
ence to opium, and should be administered hypodermically. 
When large doses are required it is well to add a small dose of 
atropin ( T j^ gr. — 0.0004 gm.) to each injection. Pulverized 
opium, deodorized opium, and the extract are suitable prepa- 
rations for use in pills. Dover's powder is the best preparation 
for promoting diaphoresis. The most agreeable liquid prepa- 
rations are the deodorized tincture and paregoric. Paregoric, 
on account of its weakness and pleasant taste, is especially 
suitable for children. The disagreeable after-effects of opium 
are often prevented by combining with it potassium bromid. 

Children are extremely intolerant to the drug in all forms, 
and, in consequence, the dose must be considerably less than 
the age would apparently justify. 

Incompatibles. — Ammonia, alkaline carbonates, prepara- 
tions containing tannic acid, or salts of the metals should not 
be prescribed in solution with morphin. Chlorids, bromids, 
iodids, and borates, when present in large amount, precipitate 
morphin from solutions. Even dilute hydrocyanic acid may 
slowly precipitate from solutions of morphin an insoluble 
cyanid of the alkaloid. 



opium. 99 

codeina, u. s. p. 

Among the alkaloids of opium codein ranks next in im- 
portance to morphin. It occurs in the form of colorless crys- 
tals, of a bitter taste, and soluble in %% parts of water and in 
1.6 parts of alcohol. The sulphate and phosphate are to be 
preferred to the alkaloid itself, on account of their greater 
solubility. The phosphate, being soluble in 2.25 parts of 
water, is adapted to hypodermic use. 

Codein resembles morphin in its action, but it is far less 
powerful as a hypnotic and analgesic. It is less liable, how- 
ever, than morphin to induce nausea and constipation. It is 
an excellent remedy for allaying irritative cough in bro?ichitis 
and phthisis. It is preferred by some clinicians to opium in 
the treatment of diabetes, but, as a rule, the crude drug or 
morphin will be found more efficacious. 

HEROIN. 

Heroin is the diacetyl ester of morphin. It appears as a 
white crystalline powder, of slightly bitter taste. It is insolu- 
ble in water, but freely soluble in acidulated solutions. It has 
a more depressant action on the respiratory center than mor- 
phin, but is less powerful than the latter as an analgesic and a 
somnifacient. The dose is from ^ 2 ~ \ S r - (0.005-0.008 gm.). 
Large doses are frequently followed by nausea, headache, dry- 
ness of the throat, vertigo, diplopia, and numbness of the limbs. 

Heroin is useful in allaying the cough of bronchitis and 
phthisis, although it is not so generally efficacious as codein. 
In emphysema and asthma it is an excellent sedative. It may 
be given in pill, powder, or in water to which a little acid has 
been added. The hydrochlorid of heroin is freely soluble, and 
may be given in aqueous solution by the mouth or hypo- 
dermically. Heroin is incompatible with alcoholics, acids, and 
apomorphin. 

DIONIN. 

Dionin is the ethyl ester of morphin hydrochlorid. It is 
freely soluble in water. According to Winternitz, it does 
not depress the respiration, and it has no unpleasant effect 
upon the stomach. As an analgesic and a somnifacient it is 
far less powerful than morphin ; as a sedative it stands probably 
midway in efficiency between codein and morphin. It may be 
prescribed in the same dose as codein. 

As a local remedy dionin has been well recommended as an 
analgesic and absorbent in certain diseases of the eye, such as 
iritis, interstitial keratitis, and corneal opacities. As it does not 



IOO SOMNIFACIENTS. 

affect sensibility, it is not suited for use in operations on the 
eye. It is usually employed in the form of a 5 or 10 per cent, 
solution or a 10 per cent, ointment. The eye rapidly acquires 
tolerance for the drug, hence little effect is to be secured from 
its use for a longer period than a week or ten days. Patients 
should be warned that the first instillation often causes marked 
swelling of the conjunctiva and eyelids. This soon subsides, 
and is of no serious import. 

PERONIN. 

Peronin is the hydrochlorid of the benzyl ester of morphin. 
It was first studied by von Mering, who found it less active 
than morphin, but freer from disagreeable after-effects. Later 
researches indicate that, while it is a somewhat more powerful 
sedative than codein, it is also more toxic. A sufficient num- 
ber of clinical observations have not yet been made to determine 
the exact rank of peronin as a therapeutic agent, but, in view 
of its slight solubility, unpleasant taste, and relatively high 
toxicity, it would seem to have few, if any, advantages over 
codein. The dose is from \-\ gr. (0.02-0.06 gm.). 

CANNABIS INDICA, U. S. P. 

( Indian Hemp ; Hashish.) 

The flowering tops of an East Indian plant, Cannabis sativa. 
It contains a resinous principle known as cannabinol. 

Preparations. Dose. 

Tinctura Cannabis Indicse, U. S. P. . . . 10-30 min. (0.6-2.0 c.c. ). 
Fluidextractum Cannabis Indicae, U. S. P. 1-5 min. (0.06-0.3 c.c). 
Extractum Cannabis Indicae, U. S. P. . . ^-1 gr. (0.008-0.06 gm. ). 

Physiologic Action. — In large doses it produces a condi- 
tion of mental exhilaration associated with hallucinations and 
disordered consciousness of time, locality, and personality. 
This stage of excitement finally gives way to sleep, which may 
last several hours. Sensation is perverted and benumbed, and 
before sleep is induced there is often more or less general anes- 
thesia. Upon the circulatory and respiratory systems the drug 
has little influence unless given in very large doses. 

Although alarming symptoms sometimes follow overdoses 
of cannabis indica, no death from its use has been recorded. 

Therapeutics. — Cannabis indica is used chiefly as a mild 
analgesic, sedative, and hypnotic. Although much inferior to 
opium, it may replace the latter when, for any reason, the 
more active drug is unavailable. It is often efficient in the 



CHLORAL. IOI 

persistent cough of chronic bronchitis and phthisis, in the dysp- 
nea of asthma, and in the restlessness and insomnia of chronic 
nephritis. As an analgesic it is very valuable in certain forms 
of netiralgia, especially migraine, in which affection it is not 
only useful between, but also during, the paroxysms. It is 
occasionally effective in relieving the violent pains of locomotor 
ataxia. It may be employed as an adjuvant to chloral in 
tetanus. In some forms of dysmenorrhea and menorrhagia it 
proves serviceable. In combination with the bromid of potas- 
sium it is sometimes useful in mania and delirium tremens. 

See and Suckling have strongly recommended it in gas- 
tralgia. 

Administration. — As the preparations of cannabis indica 
vary considerably in strength, and as some individuals are far 
more susceptible to the action of the drug than others, it is 
always advisable to begin with small doses and to increase 
them gradually. A dose of 10 drops of the tincture, repeated 
in four hours, has caused in an adult intense excitement, dila- 
tation of the pupils, and disordered sensation. 

As the addition of water or of an aqueous liquid to the 
fluid extract or tincture precipitates the resinous principle, an 
alcoholic menstruum should be selected for these preparations, 
or, in case water is used, enough mucilage should be added 
to hold the resin in suspension. 

CHLORALUM HYDRATUM, U. S. P. 

(Hydrated Chloral; Chloral, C 2 HCl s O + H 2 0.) 

Hydrated chloral is obtained from the union of a molecule of 
water with trichloraldehyd (chloral), the latter being a product 
of the action of chlorin on alcohol. It occurs in the form of 
colorless, transparent crystals, having a bitterish, caustic taste, 
a pungent odor, and a neutral reaction. It is freely soluble in 
water, alcohol, ether, and chloroform. The dose is from 10-20 
gr. (0.65-1.3 gm.). 

Physiologic Action. — Nervous System. — The dominant 
action of chloral is on the central nervous system. In moderate 
doses (i5-20gr. — 1.0-1.3 gm.)it depresses the cerebrum with- 
out sensibly disturbing the circulation and respiration, and pro- 
duces a natural sleep lasting from four to eight hours. Unlike 
morphin, it has but little effect on the algesic centers of the 
braim and, therefore, pain antagonizes its soporific action. 
Larger doses of chloral (30-40 gr. — 2.0-2.6 gm.) depress all the 
cerebral centers, including the motor, and cause profound sleep. 
Doses of this size also diminish the reflex excitability of the spina/ 



102 SOMNIFACIENTS. 

cord and depress the respiratory and vasomotor centers in the 
medulla. Toxic doses produce all the phenomena observed in 
chloroform-poisoning. On the peripheral nerves chloral has 
little or no action. 

Circulatory System. — Moderate doses of chloral do not 
affect the circulation, but large doses lower the blood-pressure 
by depressing the vasomotor center and the cardiac muscle. 

Respiratory System. — The respiration is not affected by 
ordinary doses of chloral, but after large doses it becomes in- 
frequent and shallow, and, finally, ceases from paralysis of the 
respiratory center. 

Temperature. — Toxic doses lower the temperature by di- 
lating the cutaneous vessels, by decreasing muscular move- 
ments, and probably also by depressing the heat centers in the 
brain. 

Metabolism. — The prolonged use of chloral is followed by 
increased destruction of proteids and fatty degeneration of the 
viscera. 

Local Action. — Locally, chloral is an active irritant, es- 
pecially to mucous membranes. Unless taken in dilute solu- 
tion it is very likely to cause nausea and vomiting. 

Action on Lower Org-anisms. — Chloral prevents the move- 
ments of protozoa and retards the putrefaction of proteid 
solutions. 

Elimination. — Chloral circulates in the blood as chloral, 
and is eliminated by the kidneys as urochloric acid. When 
taken in excess it escapes in part unchanged. Urine contain- 
ing urochloric acid responds to Fehling's test for sugar. 

Toxicology. — The characteristic features of acute chloral- 
poisoning are sleep, deepening into coma, a rapid feeble 
pulse, slow breathing, followed by rapid shallow breathing, 
contracted pupils, followed by dilated pupils, muscular relax- 
ation, and collapse. Death usually results from respiratory 
paralysis. 

Treatment of Poisoning-. — The temperature must be 
maintained by external heat. Brunton and Strieker found 
that an animal would stand a very much larger dose of 
chloral when the body-temperature was kept up artificially 
than when it was allowed to fall. The patient should be 
aroused by friction, flagellation, douches, etc., but should not 
be shaken or forcibly made to walk, as in opium-poisoning, on 
account of the danger of heart-failure. Cardiac and respira- 
tory stimulants like strychnin, atropin, ammonia, and digitalis 
should be given freely. Artificial respiration should be re- 
sorted to early, before the development of asphyxia. 



CHLORAL. IO3 

Chronic Poisoning" (Chloralism). — The chief symptoms of 
chronic chloral-poisoning- are nervousness, dyspnea, palpita- 
tion, insomnia, mental impairment, and a group of phenomena 
apparently due to vasomotor disturbance, such as temporary 
lividity, erythematous rashes, ecchymoses, and edema. 

Therapeutics. — Chloral is used chiefly to induce sleep 
and to allay spasm. 

Somnifacient. — It is a valuable somnifacient, inducing 
quiet and refreshing sleep. It is especially indicated for occa- 
sional use in the insomnia of overwork, excitement, sthenic 
fevers, delirium tremens, mania, and chronic nephritis. In 
sleeplessness resulting from pain it is much inferior to opium. 
In persistent insomnia it should be avoided, owing to the dan- 
ger of habituation. 

Antispasmodic. — It may be employed with advantage to 
arrest uremic and puerperal convulsions. In conjunction with 
the bromid of potassium it is perhaps the best sedative we 
possess in the convulsions of tetanus and strychnin-poisoning. 
In grave cases of epilepsy, in whooping-cough attended with 
violent paroxysms, and in chorea insaniens chloral is often 
useful, but in the milder manifestations of these diseases it 
should not be selected, on account of the depressing effect 
which follows its continued use. 

When equal parts of chloral and camphor are rubbed 
together a clear syrupy liquid is formed, which is termed 
chloral camphor. It is used as a local anesthetic in neuralgia 
and toothache. In the form of an ointment, 30-60 gr. to the 
ounce (2.0-4.0 gm. to 30.0 gm.), it is useful in pruritus. 

Contraindications. — Marked cardiac and respiratory 
weakness are contraindications to the use of chloral. In the 
chronic neuroses it must be given with considerable caution, 
on account of the danger of inducing the chloral habit 

Administration. — It is best given dissolved in some 
agreeable vehicle, as in the following formula : 

R Chlorali hydrati, gr. lxxx (5.2 gm.) ; 

Tincturse aurantii dulcis, fzss (2.0 c.c.) ; 

Syrupi aurantii, f:fj (30.0 c.c.) ; 

Aquae, q. s. f^ij (60.0 c.c). — M. 

Sig. A tablespoonful at bedtime. [Insomnia.) 

Morphin and the bromids may be given with chloral to 
enhance its effect : 

Ijt Chlorali hydrati, gr. xvj ( 1 .0 gm.) ; 

Sodii bromidi, gr. xl (2.5 gm.) ; 

Syrupi aurantii, ^3 v i ( 22 -5 c.c); 

Aquae, q. s. fglj (60.0 c.c). — M. 

Sig. A dessertspoonful every four hours for a child of three years. ( Whooping- 
cough.) 



104 SOMNIFACIENTS. 

To lessen its irritant effect when given by the bowel, chloral 
should be mixed with some demulcent, such as milk. 

Incompatibles. — Alkalies and strong solutions of anti- 
pyrin. 

BUTYL-CHLORAL HYDRAS. 

(Butyl-chloral Hydrate, Croton-chloral Hydrate, C^ClgO^O.) 

Butyl-chloral is an oily liquid formed by the action of 
chlorin on acetic aldehyd. It is converted into the solid 
butyl-chloral hydrate by the addition of water. Butyl-chloral 
hydrate occurs in the form of white pearly scales having a 
pungent odor and an acid, disagreeable taste. It is sparingly 
soluble in water, but freely so in glycerin and alcohol. The 
dose is from 5-20 gr. (0.3-1.3 gm.). 

Therapeutics. — The action of butyl-chloral hydrate is 
much the same as that of chloral hydrate, except that it is less 
powerful and more irritant to the stomach. It is generally 
supposed that the fifth nerve is especially sensitive to its seda- 
tive influence, and therefore it has been extensively employed 
in the treatment of trifacial neuralgia and migraine. 

On account of its nauseous taste, it is best given in capsules 
or in pills or dissolved in some aromatic mixture. Solutions 
should be freshly made when wanted, as the drug gradually 
decomposes when dissolved. It is incompatible with alkalies. 

CHLORALFORMAMIDUM, U. S. P. 

(Chloralformamid, Chloral amid, CCl 2 CH(OH).CONH 2 .) 

Chloralformamid, or chloralamid, is a synthetic compound 
formed by the union of chloral with formamid. It occurs in 
the form of colorless crystals, having a bitter taste, and soluble 
in 18 parts of water and \\ parts of alcohol. The dose is from 
10-30 gr. (0.65-2.0 gm.). 

Physiologic Action. — The dominant action of chloral- 
formamid is upon the cerebrum, which it depresses, causing 
profound sleep. Unlike chloral, it has little effect on the cir- 
culation, and is only a feeble depressant to the spinal cord. 
The experiments of Wood and Cerna indicate that it rather 
stimulates than depresses the respiratory center. It is slowly 
broken up in the organism into chloral and formamid, the 
latter, owing to its stimulant properties, counteracting to some 
extent the depressant action of chloral on the circulation. It 
is excreted as urochloralic acid. 

Therapeutics. — Chloralformamid is a pure hypnotic, less 
depressing and less irritating to the stomach than chloral, but 
at the same time less powerful and less prompt in its action. 



CHLORAL. I05 

It is not so slow in its action as sulphonal, and it is less liable 
than that drug to cause languor and drowsiness next day. 
Headache, giddiness, exhilaration, nausea, and inco-ordination 
are occasionally observed after its use. It has no cumulative 
effect, and patients do not readily become addicted to its use. 
It is an excellent somnifacient in chronic heart, lung, and kidney 
disease, in hysteria, neurasthenia, delirium tremens, senility, and 
acute fevers. When wakefulness is due to pain, opium is a 
better remedy, although chloralformamid seems to possess 
some analgesic properties. It has been highly recommended 
as a sedative in cardiac asthma, and, in combination with potas- 
sium bromid, as a superior remedy in seasickness. 

Administration. — Chloralformamid should be given about 
half an hour before bedtime. On account of its bitter taste 
and imperfect solubility it is better not to prescribe it in the 
form of powders. It may be conveniently given in some 
aromatic aqueous vehicle, to which a little alcohol or weak 
acid has been added to facilitate solution. It is decomposed 
by hot water. 

R Chloralformamidi, gr. lxxx (5.2 gm.) ; 

Elixiris aromatici, f^j (30.0 c.c.) ; 

Aquse, q. s. ad fgij (60.0 c.c). — M. 

Sig. A tablespoonful in water half an hour before bedtime. 

Incompatibles. — Alkalies convert it into chloral. 

CHLORALOSE. 

(Anhydroglucochloral, CgH^ClgOg.) 

Chloralose is a compound prepared by subjecting a mixture 
of equal parts of anhydrous chloral and glucose to a tem- 
perature of 212 F. for one hour. It appears in the form of 
fine colorless crystals having a bitter, disagreeable taste. It 
is freely soluble in hot water and in alcohol, and slightly so in 
cold water. The dose is from 5-8 gr. (0.32-0.5 gm.). 

Physiologic Action. — Chloralose, like chloral, induces 
sleep by directly depressing the brain. During sleep the 
reflex excitability is not diminished, but rather exaggerated, 
indicating that in ordinary doses the drug does not depress 
the spinal cord. Its somnifacient effect cannot be due to 
chloral set free in the alimentary canal, since chloralose is 
active in less than half the dose of the older hypnotic. It has 
little effect on the sensory nervous system, and is, therefore, 
only a feeble analgesic. Small doses do not generally affect the 
circulation, but large doses depress the heart. 



1 06 SOMNIFA CIEXTS. 

The great drawback to the general use of chloralose is the 
irregularity of its action: it often acts very promptly, inducing 
a refreshing sleep, lasting from six to eight hours, but not 
infrequently alarming symptoms follow its exhibition, even in 
small doses. The untoward effects are retardation of the 
pulse, dilatation of the pupils, deafness, tremors, extreme 
prostration, cyanosis, incoherent speech, convulsive seizures, 
nausea, profuse sweating, and incontinence of urine and feces. 
In neurotic subjects it may induce delirious excitement instead 
of sleep. 

Therapeutics. — Chloralose has been used with some suc- 
cess in functional insomnia. Tyson has found it effective in 
the sleeplessness of chronic heart-disease and Bright s disi 
Balfour also speaks favorably of its action in the insomnia 
associated with heart-disease. The drug should be avoided 
when there is great debility-. 

Administration. — Chloralose is best administered in 
cachets or capsules, followed by a draught of hot milk or tea. 

CHLORETONE. 
(Aneson, Trichlortertiary Butyl Alcohol, CCl 3 C(CH 3 ) 2 OH. 

..loretone is a compound formed by the addition of caustic 
potash to equal weights of chloroform and acetone. It is a 
white crystalline powder, with a camphoraceous odor and taste. 
It is sparingly soluble in cold water, but freely so in ether and 
strong alcohol. The dose is from 5-20 gr. (0.3-1.3 g: 

Physiologic Action. — Chloretone has two important 
actions: it is a somr j a local anesthetic. In ani- 

mals large doses reduce the temperature and also lower the 
blood-pressure, probably by depressing the heart and the vaso- 
motor center. Impens considers the drug to be more toxic 

n chloral. It probably undergoes decomposition in the 
body, since after its ingestion neither chloretone itself nor its 
components (chloroform and acetone | are found in the urine. 
It has pronounced germicidal properties. 

Therapeutics. — Chloretone may be regarded as a reason- 
ably onotic of moderate power. It is prompt in its 
action, sleep usually following in from half an hour to an 
hour after its administration. Beyond causing slight drowsi- 
ness on the day following its exhibition, it rarely gives rise to 
unpleasant after-effects. Toleration of the drug is rather 
rapidly acquired by continuous use. It is especially adapted 
for use in cases of insomnia unattended with severe pain, iiigh 
-. ox pronounced nervous excitement. It has been used with 
some success as a sedative in sea-sickness and noctu epsy. 



Sl'LPHOXAL. 107 

As a local anesthetic and antiseptic it has proved service- 
able in minor surgery. It may be applied in the form of a 
dusting-powder to wounds y burns, and painful ulcers. 

hloietone (5 per cent, serves as a preservative of solutions 
of organic compounds (adrenalin, homatropin). 

Administration. — It may be given in tablets, cachets, or 
powders, followed by a draught of water. 

SULPHONMETHANUM. U. 3. P. 

(Sulphonmethan, Sulphonal, (CH 3 ) 2 C(S0 2 C 2 H 3 ) 2 .) 

Sulphonal is a synthetic compound obtained by oxidizing a 
mixture of ethyl hydrosulphid and acetone. It occurs as 
a colorless, crystalline powder, free from odor and taste. It 
is soluble in 360 parts of cold water, 1 5 parts of boiling water, 
and 47 parts of alcohol. The dose is from 15-30 gr. (1.0- 
2.0 gi 

Physiologic Action. — In moderate doses sulphonal is a 
pure hypnotic, inducing sleep by a direct action on the cere- 
brum. Owing to its insolubility- in gastric juice it is very 
slowly absorbed from the stomach, and when given in the 
form of a powder its soporific effect may not be manifest for 
several hours or, after a late dose, not until the following day. 
In ordinary amounts it does not influence the circulation or 
respiration, and rarely the digestion. Drowsiness, headache, 
vertigo, mental confusion, and cutaneous rashes are sometimes 
noted after its use. When exhibited in single doses, or in 
short courses not exceeding a week or two, sulphonal may be 
regarded as a safe hypnotic, rarely producing unpleasant symp- 
toms. It has no analgesic properties. 

Toxicology. — Acute sulphonal-poisoning does not com- 
monly prove fatal, probably because much of the drug escar es 
from the stomach before absorbtion takes place. r re- 

| : r:5 the case of a person who took a tablespoonful of 
drug, and slept in consequence four days and nights, and then 
rapidly convalesced ; and another patient, aged fifteen ye 
who took nearly 3 ounces and was unconscious for five c 
rec ivering entirely in eight c. : 

Death, he wever, has followed the ingestion of comparatively 
small amounts. Murrell has cited two instances of death from 
30 and 40 grains respectively. 

The symptoms of acute poisoning are headache, vertigo, 
tinnitus aurium, marked cyanosis, vomiting, diarrhea, shallow 
breathing, feeble pulse, dilated pupils, unconsciousness, and 
collapse. The treatment consists in administering saline ca- 



Ib8 SOMNIFACIENTS. 

thartics and quickly acting stimulants (strychnin, ammonia), 
and in maintaining the body-temperature. 

Chronic sulphonal-poisoning has frequently followed the 
continuous use of the drug for weeks or months. Seven- 
teen out of 20 cases collected by H. C. Wood, Jr., terminated 
fatally. Probably from the gradual accumulation of the drug 
in the body the symptoms often appear abruptly, sometimes 
even after the habit has been suspended for several days. 
The chief phenomena of chronic poisoning are a peculiar red 
coloration of the urine, languor, ataxia, progressive weakness, 
paralysis, paresthesia, nausea, vomiting, colicky pains, serous 
diarrhea or obstinate constipation, insomnia, and mental con- 
fusion. In unfavorable cases the urine becomes scanty and 
albuminous, and the exhaustion deepens into collapse. In a 
fatal case reported by Taylor and Sailer well-marked degen- 
erative changes were found in the liver, kidneys, and heart. 
The discoloration of the urine, which is of considerable diag- 
nostic import, is due to the presence of hematoporphyrin, a 
compound thought to be derived from hematin. 

The treatment of chronic poisoning consists in withdrawing 
the drug at once, and in freely administering alkaline carbon- 
ates (sodium carbonate) with saline cathartics. Hypodermo- 
clysis and enteroclysis are also recommended by Wood. 

Therapeutics. — It is an excellent hypnotic in the insomnia 
of nervous excitement, overwork, and mental disease. When 
sleeplessness is due to pain, it is ineffective. In chronic dis- 
ease of the heart, lungs, or kidneys, sulphonal is not, as a 
rule, to be chosen. 

Administration. — Sulphonal is best administered in some 
hot liquid, and, as its action is slow, it is well to give it an 
hour or two before bedtime. Compressed tablets should be 
avoided. On account of its tendency to accumulate in the 
body, it should not be given continuously for more than a 
week. Even after its exhibition for several successive days, 
it is advisable to order a saline cathartic for the purpose of 
removing from the bowel any portion of the drug remaining 
unabsorbed. 

SULPHONETHYLMETHANUM, U. S. P. 

(Sulphonethylmethan, Trional, (C 2 H 5 .CH 3 .C(S0 2 C 2 H 6 ) 2 .) 

Trional, like sulphonal, belongs to the group of " sul- 
phones," i. e., combinations of So 2 with organic radicles. Sul- 
phonal, trional, and tetronal contain respectively two, three, 
and four molecules of ethyl. It occurs in the form of color- 
less, flat crystals, free from odor, and almost tasteless. It is 



PARALDEHYDUM. IO9 

soluble in 195 parts of cold water, and freely soluble in hot 
water, ether, and alcohol. The dose is from 15-30 gr. (1.0- 
2.0 gm.). 

Physiologic Action and Therapeutics. — The action 
of trional is almost identical with that of sulphonal. Owing to 
its greater solubility, however, it is more prompt in its effect, 
and has less tendency to accumulate in the body. When not 
used too continuously, it is a safe and reliable hypnotic, suit- 
able for the same class of cases in which sulphonal is most 
effective. It is best given in some warm vehicle — milk, tea, 
or whisky — an hour or two before retiring. Occasionally it 
gives rise to headache, drowsiness, and nausea on the day 
following its administration. When used continuously for 
several weeks, it causes the following toxic symptoms : head- 
ache, vertigo, impairment of memory, disordered speech, 
tremors, nausea, constipation or diarrhea, colicky pains, hema- 
toporphyrinuria, oliguria, and even strangury. These symp- 
toms, however, do not, as a rule, develop so abruptly as they 
do after the prolonged use of sulphonal. The treatment does 
not differ from that of sulphonal-poisoning. 

TETRONAL. 

((C 2 H 5 ) 2 .C.(S0 2 C 2 H 5 ) 2 .) 

Tetronal is an analogue of trional and sulphonal, containing 
four ethyl groups. It is used in the same doses and for the 
same purposes as trional. It has no advantages over the 
latter; on the contrary, it is less soluble and much more 
costly. 

PARALDEHYDUM, U. S. P. 

(Paraldehyd, C 6 H 12 3 .) 

Paraldehyd is a product obtained by treating aldehyd with 
dilute sulphuric or nitric acid. It appears as a colorless 
liquid, having a strong ethereal odor and a disagreeable, pun- 
gent taste. It is soluble in 8.5 parts of water, and is miscible 
in all proportions with alcohol, ether, chloroform, and oils. 
The dose is |— 1 fl. dr. (2.0-4.0 c.c). 

Physiologic Action. — The action of paraldehyd some- 
what resembles that of chloral. Like the latter, it depresses 
the brain and spinal cord. Although it causes a sensible fall in 
the arterial pressure, it is not so depressing to the heart itself 
as chloral. Large doses are prone to disturb the stomach. It 
is eliminated by the lungs and kidneys. Toxic doses produce 
coma, feeble breathing, great muscular relaxation, abolition of 



1 1 SOMNIFA C 'IE NTS. 

reflex activity, and, finally, death from paralysis of the respira- 
tory center. Its long-continued use is sometimes followed by 
cutaneous eruptions. It has no analgesic properties. 

Therapeutics.— Paraldehyd is a safe and reliable hyp- 
notic. The great drawbacks to its use are its unpleasant taste 
and the disagreeable odor which it imparts to the breath for 
twenty-four hours after its ingestion. Toleration is some- 
what rapidly acquired. It may be employed with advantage 
in the insomnia of mania, delirium tremens, hysteria, and heart- 
disease. It is sometimes efficient as an antispasmodic in 
asthma. It has also been used with some success in control- 
ling the convulsions of tetanus. 

Administration. — It may be prescribed in capsules or in 
some aromatic vehicle. A few drops of alcohol render it 
freely miscible with water. The dose should be well diluted. 

R Paraldehyde 
Glycerin i, 

Spiritus aurantii compositi, aa f^iv ; 

Aquse, q. s. ad f^ij. — M. 

Sig. A dessertspoonful in water, repeated in an hour if necessary. 

iETHYLIS CARBAMAS, U. S. P. 

(Ethyl Carbamate, Urethane, NH 2 .CO.OC 2 H 5 .) 

Ethyl carbamate, or urethane, is made by the interaction of 
ethyl alcohol and nitrate of urea. It occurs as colorless tabular 
crystals, odorless, and having a cooling saline taste. It is 
readily soluble in water, alcohol, ether, and chloroform. The 
dose is from 15-45 gr. (1.0-3.0 gm.). 

Physiologic Action and Therapeutics. — Urethane is a 
comparatively safe hypnotic, without influence in ordinary 
doses upon the respiration and circulation, but mild and some- 
what uncertain in action. It has no analgesic effect. Toxic 
doses are followed by coma, a fall of temperature, weakness 
of the pulse, abolition of reflex activity, and death from respi- 
ratory paralysis. It is excreted as urea. It may be successfully 
employed in insomnia from nervous excitement or insanity. It 
is not without value as an anticonvulsant. Dana and Jacobi 
have spoken very favorably of its action in some cases of 
epilepsy. 

Urethane is incompatible with acids and alkalies. Rubbed 
with chloretone it produces a liquid compound. 



POTASSII BROMIDUM. Ill 

HEDONAL. 

(Methylpropylcarbinolurethane, C 6 H 13 2 N.) 

Hedonal is a synthetic compound closely allied to urethane. 
It occurs as a white crystalline powder, of a menthol-like 
taste, almost insoluble in water, but soluble in alcohol and 
ether. As a somnifacient it is more prompt and effective than 
urethane, but distinctly less powerful than chloral, trional, or 
sulphonal. It usually produces, within from J to I hour, 
quiet sleep, lasting from 4 to 8 hours, without unpleasant 
after-effects. It is an agreeable and safe somnifacient, only 
suitable, however, for very mild forms of insomnia, unaccom- 
panied by pain or excitement. It is most effective in doses of 
from 20-30 gr. (1.3-2.0 gm.), in dry powder or in capsules. 

VERONAL. 

( Diethylmalonylurea, Diethylbarbituric acid, C 8 H, 2 N 2 3 .) 

Like urethane and hedonal, veronal also belongs to the 
urea group of somnifacients. It is a white crystalline powder, 
of a faintly bitter taste, soluble in 145 parts of cold water and 
in 1 2 parts of boiling water. It appears to be a comparatively 
safe, prompt, and reliable somnifacient, producing, in from \ 
to 1 hour a quiet sleep, lasting from 5 to 10 hours. Occa- 
sionally, its use is followed by lassitude, dulness, and anorexia. 
In a few cases toxic symptoms, such as somnolence, dryness 
of the throat, elevation of temperature, an erythematous rash, 
and prostration, have resulted from the repeated administration 
of the drug. It may be employed with advantage in cases of 
simple insomnia, unaccompanied by pain or marked excitement. 
The dose is from 8-15 gr. (0.5-1.0 gm.). It is best given in 
hot tea or milk, or in capsules followed by some warm liquid. 

POTASSII BROMIDUM, U. S. P. 

(Potassium Bromid, KBr.) 

Potassium bromid occurs in colorless or white cubical 
crystals, odorless, and having a pungent saline taste. It is 
soluble in 1.6 parts of water and in 200 parts of alcohol. The 
dose is from 10-60 gr. (0.65-4 gm.). 

Physiologic Action. — Circulatory System. — Small 
doses have no influence, but large doses, owing to the presence 
of the potassium base, exert a depressant action on the heart. 

Nervous System. — The bromid ion, irrespective of the base 
with which it is combined, depresses the entire central nervous 
system — cerebrum, spinal cord, and medulla — psychic, motor, 



1 1 2 SOMNIFA C IE NTS. 

and sensory functions all being involved. By depressing the 
psychic centers it causes apathy, lapse of memory, and con- 
fusion of thought ; by depressing the motor area of the brain 
it lessens the power of irritants to excite epileptiform convul- 
sions ; and by depressing the spinal cord and medulla it 
diminishes reflex activity, blunts the sensibility of the mucous 
membranes, and impairs muscular coordination. Large doses 
of a bromid promote sleep by lessening the sensitiveness of 
the cerebrum to all centripetal stimuli. They also reduce or 
abolish sexual feeling by a similar central action. 

Wright and Crisafulli have found after poisonous doses 
marked degenerative changes (vacuolation and atrophy) of the 
cortical nerve-cells. 

Respiratory System. — The respiratory centers share with 
other parts of the nervous system in the depression caused by 
large doses of bromids, and in fatal poisoning respiration may 
fail before the heart ceases to beat. 

Alimentary Canal. — In concentrated form potassium bro- 
mid acts as an irritant to the stomach, and may occasion 
nausea and vomiting. 

Absorption and Elimination. — Potassium bromid is rapidly 
absorbed, and may appear unchanged in the urine within 
fifteen minutes after its ingestion. Elimination is not effected 
as rapidly as absorption, hence there is a tendency for the drug 
to accumulate in the body. Small quantities of bromid are 
also excreted by the skin, respiratory tract, and bowel. 

Bromism. — The continuous use of bromids is usually fol- 
lowed by a group of symptoms to which the term bromism 
has been applied. This condition is characterized by anemia, 
a general eruption of acne, fetor of the breath, gastric disturb- 
ance, mental depression, somnolence, failure of memory, aboli- 
tion of the sexual appetite, diminution of the reflexes, impair- 
ment of tactile sensibility, unsteady gait, and muscular weakness. 

Exceptional Effects of Bromids. — The continued exhi- 
bition of bromids in large doses is occasionally followed by 
one of the following symptoms : Paresis of the limbs, ptosis, 
depression of the heart, intense irritability of temper, depres- 
sion of spirits, and suicidal or homicidal impulses. 

Acute Poisoning". — The chief symptoms resulting from 
the ingestion of a single toxic dose of potassium bromid are 
severe headache, inco-ordination, somnolence, dilatation of 
the pupils, burning in the stomach, and collapse. No fatal 
case of bromid-poisoning has been reported. 

Action of Potassium Bromid Compared with Other 
Bromids. — On account of the relatively large amount of po- 



POTASS II BROMIDUM. 1 1 3 

tassium (44 per cent.), this salt is the most powerful depressant 
of all the bromids. 

Therapeutics. — Potassium bromid is used to control con- 
vulsions, to allay nervous excitement, to promote sleep, and 
to relieve certain forms of headache and neuralgia. 

To Control Convulsions. — The bromids are by far the 
most useful drugs we possess in the treatment of epilepsy. 
They not only exert a direct sedative influence on the cerebral 
cortex, but through their action on the sensory neurons of the 
spinal cord they protect the brain from the disturbing influ- 
ence of external stimuli. While they rarely effect a cure, they 
very often lessen materially the frequency of the paroxysms. 
The amount required varies with the severity of the case 
and the susceptibility of the individual, and must be deter- 
mined experimentally in each case. Saturation is indicated 
by a loss of the palatal reflex, mental hebetude, and gastric 
disturbance. The daily dose usually ranges between 1 and 2 
dr. (4.0-8 o gm.). When larger doses than these are required, 
it is better to try a combination of other remedies with the 
bromid than to depend upon the latter alone. Sometimes 
small doses of potassium iodid, or moderate doses of antipyrin 
or acetanilid, will serve to lessen the amount of bromid re- 
quired. A combination of several bromids often acts more satis- 
factorily than a single bromid. In nocturnal epilepsy the occa- 
sional exhibition of chloretone or sulphonal with the bromid 
often proves very efficacious. When the circulation is weak a 
combination of a bromid with digitalis or of adonis venalis, as 
recommended by Bechterew, will be found useful. It has 
been shown by Richet and Toulouse that the deprivation of 
salt from food very decidedly increases the efficacy of the 
bromid treatment. The addition of a drop or two of Fowler's 
solution to each dose of the bromid often prevents the out- 
break of acne. 

In some cases of epilepsy it is necessary to withhold the 
bromids entirely, since the general disturbance which they 
occasion more than counterbalances the good they accom- 
plish in diminishing the number of seizures. 

The bromids are of considerable value also in other con- 
vulsive disorders besides epilepsy, such as puerperal eclampsia, 
uremia, infantile convulsions, strychnin-poisoning, and tetanus. 
In severe cases of chorea with incessant movements the bromids 
may be employed, but they are less efficient than chloral. In 
local spasmodic affections — whooping-cough, laryngismus st?id- 
ulus, and essential asthma — bromids are sometimes of service. 

To Allay Nervous Excitement. — In nervous irritability of 
all kinds potassium bromid is useful. It is an excellent seda- 



1 14 SOMNIFACIENTS. 

tive in the excitement of overwork, worry \ and anxiety, and 
also in that which attends hysteria. In the varied nervous 
disturbances which attend the menopause it is our most reliable 
remedy. In fully developed delirium tremens it is of little 
value, but in the stage of excitement which precedes the latter 
it is very efficient. 

Potassium bromid is a powerful anaphrodisiac ; by dimin- 
ishing the irritability of the sexual centers in the spinal cord it 
renders excellent service in priapism, spermatorrhea, and 
nymphomania. 

Given for several days before the expected voyage, in doses 
of from 10-20 gr. (0.65-1.3 gm.), three times a day, it often 
prevents sea-sickness. It may also be tried in the vomiting of 
pregnancy. Da Costa found that from 30-60 gr. (2.0-4.0 
gm.) of potassium bromid, administered an hour before a 
dose of opium, would prevent the disagreeable after-effects 
of the latter. 

To Promote Sleep. — As pure hypnotics the bromids are 
feeble compared with opium and chloral, but in insomnia due 
to nervous excitement they frequently produce refreshing 
sleep. 

To Relieve Headache and Neuralgia. — Potassium bromid 
is often useful in attacks of migraine, trifacial neuralgia, and 
the headache of cerebral congestion. In these affections it may 
be given alone or in combination with antipyrin, phenacetin, 
caffein, or a salicylic compound. 

Administration. — Potassium bromid should be given in 
solution, well diluted, after meals. In epilepsy it is best to 
divide the daily dose according to the time at which the seiz- 
ures are likely to occur. Thus in nocturnal epilepsy compara- 
tively small doses may be given early in the day, and a very 
large dose (J— I dr. — 2.0-4.0 gm.) at supper-time. The bromid 
may be combined with antipyrin and Fowler's solution, as in 
the following formula suggested by Wood : 

R Potassii bromidi, 

Ammonii bromidi, aa sjiij (12.0 gm.) ; 

Liquoris potassii arsenitis, f^j (4.0 c.c.) ; 

Antipyrinae, %] (4.0 gm.) ; 

Aquae menthae piperitae, q. s. ad f^vj (180.0 c.c). — M. 

Sig. Tablespoonful in water night and morning. 

In insomnia from nervous excitement potassium bromid may 
be combined with chloral, as in the following formula : 

R Chlorali hydrati, gr. xl (2.6 gm.) ; 

Potassii bromidi, ^iss (6.0 gm.) ; 

Aquae et syrupi aurantii, aaq.s. ad f^ij (60.0 c.c). — M. 
Sig. Tablespoonful in water at bedtime. 



P OTA SSI I BROMIDUM. I.15 

Incompatibles. — Potassium bromid is incompatible with 
acids and acid salts. It also precipitates certain alkaloids — 
morphin, quinin, and strychnin — from neutral solutions. 

AMMONII BROMIDUM, U. S. P. 

(Ammonium Bromid, NH 4 Br.) 

Bromid of ammonium occurs in the form of white crystals 
or as a yellowish-white powder having a disagreeable salty 
taste. It dissolves in 1.2 parts of water and in 12.5 of alcohol. 
Its dose is from 20-60 gr. (1.3-4.0 gm.), well diluted. 

Physiologic Action. — The dominant action of ammonium 
bromid, like the corresponding potassium salt, is on the nervous 
system. It depresses the cortical brain-cells, and both the sen- 
sory and motor neurons of the spinal cord, especially the for- 
mer. It differs in its action from potassium bromid in being 
less depressing to the heart, muscles, and peripheral nerves. 

Therapeutics. — It may be substituted with advantage for 
the potassium salt in all the conditions in which a bromid is 
indicated. 

Incompatibles. — The same as in the case of potassium 
bromid, and, in addition, spirit of nitrous ether. 

SODII BROMIDUM, U. S. P. 

(Sodium Bromid, NaBr.) 

Sodium bromid occurs in colorless or white cubical crystals, 
or as a white granular powder, odorless, and of a saline, bitter 
taste. It is soluble in 1.7 parts of water and in 12.5 of alcohol. 
It contains 78 per cent, of bromin. The dose is from 20-60 
gr. (1.3-4.0 gm.), well diluted. 

Physiologic Action and Therapeutics. — Its action 
closely resembles that of potassium bromid, but it is less 
irritating to the stomach and somewhat less depressing. It 
may be used as a substitute for the potassium salt in the vari- 
ous conditions in which a bromid is indicated. 

STRONTII BROMIDUM, U. S. P. 

(Strontium Bromid, SrBr 2 .6H 2 0.) 

Strontium bromid occurs in colorless, very deliquescent, 
hexagonal crystals, odorless, and of a bitter, saline taste. It 
is readily soluble in water and in alcohol. The dose is from 
30-60 gr. (2.0-4.0 gm.). 

Therapeutics. — Strontium bromid has an action on the 
nervous system similar to that of the other bromids, but it is 



Il6 SOMNIFACIENTS. 

less powerful. At the same time it is less depressing - , less 
prone to cause acne, and, instead of disturbing the stomach, it 
tends rather to allay gastric irritation. It may be used as a 
succedaneum for other bromids when only a mild effect is 
required or when there is irritability of the stomach. In other 
cases it may be combined with potassium or ammonium bromid 
to mitigate their unpleasant by-effects. Germain See and 
others have spoken favorably of its action in gaslralgia and 
acid dyspepsia. 

LITHII BROMIDUM, U. S. P. 

(Lithium Bromid, LiBr.) 

Lithium bromid is a white, granular, deliquescent salt, odor- 
less, of a sharp, bitter taste. It is freely soluble in water and 
in alcohol. The dose is from 20-60 gr. (1.3-4.0 gm.). 

Therapeutics. — Lithium bromid has a therapeutic value 
about equal to that of sodium bromid. 

ACIDUM HYDROBROMICUM DILUTUM, U. S. P. 

(Diluted Hydrobromic Acid, HBr.) 

Diluted hydrobromic acid is an odorless, colorless liquid, 
of acid properties, composed of 10 per cent, by weight of abso- 
lute hydrobromic acid and 90 per cent, of water. The dose is 
from 1-4 fl. dr. (4.0-15.0 c.c), well diluted. 

Therapeutics. — Hydrobromic acid has very much the 
same action as the bromids. It differs from potassium bromid 
in being less powerful, less likely to cause acne and general 
depression, and in being more irritating to the stomach. 

It may be given alone or in combination with bromids in 
epilepsy and other convulsive disorders. It is especially valu- 
able in tinnitus aurium resulting from aural disease or following 
the administration of quinin or salicylic compounds. It has 
been employed as a sedative in febrile excitement, whooping- 
cough, and nervous headache. The following combination of 
dilute hydrobromic acid and horse-nettle is sometimes effica- 
cious in the milder forms of epilepsy : 

I£ Acidi hydrobromici diluti, 

Fluidextracti solani carolinensis aa f§iss (45.0 c.c.) ; 
Syrupi aurantii, ffj (30.0 c.c.) ; 

Aquae, q. s. ad fijvj (180.0 c.c). — M. 

Sig. A tablespoonful in water after meals. 

BROMOFORM, U. S. P. 

(Bromoform; Tribrommethane, CHB 3 .) 

Bromoform is made by the action of hypobromite of sodium 
on acetone, or of bromine on a mixture of methyl alcohol and 



BROMOFORM. 1 1 J 

milk of lime. It appears as a clear, colorless liquid having a 
pleasant odor and a sweetish taste. It is sparingly soluble in 
water, but freely so in alcohol and glycerin. The dose is from 
1-6 min. (0.06-0.4 c.c). To be fit for use it should be free 
from color and acidity. 

Therapeutics. — Bromoform has anesthetic properties 
iomewhat analogous to those of chloroform, but as a thera- 
peutic agent it is of interest chiefly as an internal remedy in 
zv hooping-cough. While it has a definite value in lessening 
the severity of the paroxysms, it has no power to shorten the 
duration of the disease. 

Toxicology. — Many cases of poisoning by bromoform 
have been reported since its first introduction as a remedy for 
whooping-cough. Very often the accident has resulted from 
a lack of familiarity with the physical properties of the drug. 
As bromoform is heavier than mucilage, its suspension in the 
latter can only be temporary ; it naturally tends to fall to the 
bottom of the bottle, and unless this is prevented by frequent 
and thorough shaking, a much larger dose may be taken on 
emptying the bottle than w T as intended. The chief phenomenon 
of bromoform-poisoning is a kind of intoxication, followed by 
coma, marked cyanosis, difficult breathing, a rapid, feeble pulse, 
muscular relaxation, and collapse. In some cases the coma 
has been interrupted by general convulsions. Death usually 
results from asphyxia. 

Treatment consists in the evacuation of the stomach, the 
practice of artificial respiration, and the administration of 
cardiac and respiratory stimulants. 

Administration. — It may be administered by simply 
dropping it on sugar or into a little peppermint-water. On 
account of its high specific gravity a minim is equal to about 
6 drops. If suspended in mucilaginous liquids, the bottle 
must be well shaken before each administration. As it is 
soluble in alcohol and glycerin, a mixture of these liquids 
may be made the vehicle, as in the following formula: 

R Bromoformi, tT[xx-xxx (1.2-1.8 c.c.) ; 

Alcoholis, f^ij (8.0 c.c.) ; 

Spiritus menthse piperitse, tTi xx ( I -3 c.c). ; 

Glycerini, fgij (60.0 c.c). — M. 

Sig. — A teaspoonful four times a day for a child of two years. 

HYOSCIN^ HYDROBROMIDUM, U. S. P. 

(Hyoscin Hydrobromid. ) 

Hyoscin (see p. 83) is a useful somnifacient when sleepless- 
ness is attended by great mental and motor excitement. Thus 



Il8 GENERAL ANESTHETICS. 

it often acts favorably in mania, melancholia agitata, delirium 
tremens, and chorea insaniens. In chronic heart disease, while 
it is sometimes efficacious, it is not so generally useful as mor- 
phin. The dose is from T | 7 \ gr. (0.0004-0.0008 gm.). 



GENERAL ANESTHETICS. 

General anesthetics are volatile drugs which when absorbed 
by the lungs induce unconsciousness and insensibility. They 
are employed to abolish or lessen pain and to relax spasm. 
They are used for both of these purposes in surgical opera- 
tions, in labor, and in biliary and renal colic. They are of 
service in subduing the convulsive seizures of tetanus, strych- 
nin-poisoning, and uremia. By suspending muscular irritabil- 
ity they also render valuable aid in the reduction of luxations, 
fractures, and strangulated hernias, and in the recognition of 
deep-seated abdominal lesions. The most important general 
anesthetics are: 



Ether. 




Nitrous oxid. 


Chloroform. 




Ethyl 


bromid. 




Ethy 


1 chlorid. 





^THER, U. S. P. 

(Ether, Ethyl Oxid, C 4 H, O.) 

Ether is obtained by the action of sulphuric acid on alcohol, 
and appears as a colorless, volatile, highly inflammable liquid, 
having a strong characteristic odor. It is soluble in alcohol, 
chloroform, oils, and water. The official preparation contains 
about 4 per cent, of alcohol. 

Preparations. Dosy. 

Spiritus Athens, U. S. P. ...... . 1-3 fl. dr. (3.5-1 1.0 c.c). 

Spiritus yEtheris Compositus, U. S. P. . . . \-\ fl. dr. (2.0-3.5 c - c -)- 

Physiologic Action. — When freely inhaled ether first 
causes coughing, choking, and a sense of strangulation from 
its irritant effect on the mucous membrane of the respiratory 
tract. Soon it induces flushing of the face, injection of the 
eyes, dilatation of the pupils, irregularity in breathing, and an 
increase in the rate and strength of the pulse. Frequently 
marked emotional excitement develops, characterized by shout- 
ing, crying, laughing, or violent struggling. These phenomena 
gradually subside, and are followed by complete unconscious- 
ness, muscular relaxation, moderate contraction of the pupils, 



jEther. 119 

abolition of the reflexes, slight cyanosis, regular but shallow 
breathing, a decrease in the rate and strength of the pulse, and 
some lowering of the body temperature. If the anesthetic be 
pushed still further, the face becomes pale or deeply cyanosed, 
the pulse grows feeble, the respirations become slow and very 
shallow, the sphincters relax, the pupils dilate, and finally 
death ensues, usually from failure of respiration. 

Circulatory System. — The increase in the rate and 
strength of the pulse observed at the beginning of anesthesia 
is due in part to general excitement and partly to reflex stimu- 
lation of the heart from irritation of the air passages. Hypo- 
dermic injections of ether, as of alcohol, may also cause 
transient stimulation of the heart by inducing local irritation. 
The drug probably never directly stimulates the heart. In 
advanced anesthesia the blood-pressure falls, owing to depres- 
sion of the heart and vasomotor center. 

Respiratory System. — The irregular breathing often noted 
at the commencement of anesthesia is due partly to excitement 
and partly to irritation of the nasal mucous membrane. The 
failure of respiration occurring from overdoses of ether is the 
result of direct depression of the respiratory center, though in 
the majority of cases low blood-pressure in the medulla is an 
important contributing factor. Unless the cardiac weakness is 
too pronounced, respiratory failure can nearly always be over- 
come by artificial respiration. It should be borne in mind that 
the ill effects of ether on both the respiration and circulation 
are much more closely related to the degree of concentration 
in which it is administered than to the actual amount of it 
inhaled. 

Nervous System. — Ether directly depresses the entire cen- 
tral nervous system, the cerebrum being first affected, then the 
spinal cord, and last of all the medulla. The sensory neurons 
are probably acted upon before the motor. From 5 to 6 per 
cent, of ether must be present in the inspired air to produce 
complete anesthesia in human beings. 

Pupils. — The pupils are dilated at first as the result of 
excitement. During the period of anesthesia they are con- 
tracted as in sleep. Dilatation again occurs when conscious- 
ness is returning or when death is imminent from bulbar 
paralysis. 

Temperature. — Etherization always lowers the body tem- 
perature and, therefore, it is important that the operating room 
should be well heated and the patient should be guarded 
against exposure. The fall of temperature is due partly to 
increased loss of heat from dilatation of the cutaneous vessels. 



120 GENERAL ANESTHETICS. 

and partly to decreased production of heat from the absence 
of muscular movements. 

Blood. — The studies of Da Costa and Kalteyer and others 
indicate that anesthetics increase hemolysis, and thus reduce 
the percentage of hemoglobin. A slight polycythemia, how- 
ever, is often observed at the close of anesthesia, probably from 
concentration of the blood. 

Local Action. — When applied to the skin, ether evaporates 
quickly, produces intense cold, and thus benumbs the periph- 
eral nerves. Local irritation, sometimes sufficient to cause 
inflammation and even vesication, may follow if the evapora- 
tion is prevented. Inhaled, it causes considerable irritation of 
the mucous membrane of the respiratory tract, and thus leads 
to a profuse secretion of saliva and mucus. During anesthesia 
a certain amount of ether is swallowed with the mucus and 
causes nausea and vomiting. 

Elimination. — Ether leaves the body mainly by the lungs, 
though a small amount is excreted by the kidneys. On the 
latter the drug has a decidedly irritant effect, and, therefore, 
considerable caution must be exercised in its employment as a 
general anesthetic when there are evidences of serious nephri- 
tis. After prolonged anesthesia the urine may contain not 
only albumin and casts but also certain bodies the result of 
disturbed metabolism, such as glucose, acetone, and diacetic 
acid. 

Therapeutics. — Ether was first employed as an anesthetic 
in general surgery by William T. G. Morton, at the Massa- 
chusetts General Hospital in 1846; since that time it has been, 
in this country, the most extensively used anesthetic in all 
operations excepting the most trivial. 

The Administration of Ether as an Anesthetic. — 
When administered as an anesthetic the following precautions 
should be observed : No solid food should be taken for several 
hours before the operation. If there has been nausea or if the 
patient is very weak, a little brandy may be given prior to the 
anesthetic. When given to a female, a third person should 
always be present. Before its administration the teeth should 
be examined, and, if false, they should be removed. The 
throat and waist should be freed from tight clothing, but the 
patient should not be exposed, as inflammation of the lungs is 
liable to follow when this precaution is unheeded. 

The anesthetizer must guard against placing the head and 
arms of the patient in positions likely to cause pressure on 
nerve-trunks. The eyes should be covered with a pad of 
moistened gauze and the lips and nostrils anointed with petro- 



JZTHER. 121 

latum to protect them from the irritant action of the ether. As 
the vapor of ether is highly inflammable, and since it is heavier 
than air, it is necessary when operating by gas-light to have 
the jet above the operator. In using the actual cautery special 
care is necessary to prevent ignition. No more ether should 
be used than is absolutely necessary to induce and maintain 
the desired degree of anesthesia. The anesthetizer should be 
continually on the lookout for any irregularities in the respira- 
tion or pulse and for changes in the facial appearance. 

Ether may be administered from a towel loosely folded in 
the form of a cone, surrounded by stiff paper, and enclosing 
at its tip a small sponge, or, better, from an open inhaler made 
especially for the purpose. At first the inhaler should be 
held some distance from the nose, to accustom the patient to 
the irritant effects of the ether, but soon it should be brought 
close to the nose, so that the anesthetic may be inhaled in a 
more concentrated form. Regular snoring respiration, muscu- 
lar relaxation, and insensibility of the conjunctivae are the indi- 
cations that the patient is prepared for the operation. Admin- 
istration by the " drop method " or " open method," which is 
now adopted in many hospitals, has much to recommend it. It 
consists in pouring ether, drop by drop, slowly but continuously 
upon several layers of gauze (six or eight), supported by a wire- 
framed mask. Complete narcosis is produced in from eight to 
ten minutes. With this method there is much less tendency 
to coughing, struggling, and retching, the secretion of mucus 
is not nearly so profuse, and the frequency of after-sickness is 
notably reduced. 

The quantity of ether required for an ordinary operation, 
lasting about an hour, is usually from 6 to 10 ounces (180- 
300 c.c), more being necessary with the open method than 
the older one. 

Accidents During Anesthesia. — The most common 
accident during etherization is failure of respiration. When 
this occurs after the first few inhalations, it is generally the 
result of a reflex spasm of the laryngeal muscles excited by 
the ether. The admixture of a little more air with the vapor 
will serve to relax the spasm, when respiration will be resumed. 
Embarrassed respiration is often due to the accumulation of 
mucus in the upper air-passages or to the tongue falling back 
into the throat. In the event of the former accident the head 
should be turned to one side, when much of the fluid will run 
out or will collect in the dependent cheek, from which it may 
be removed by means of a sponge held by forceps. In the 
event of the latter accident, it will be necessary to press the 



122 GENERAL ANESTHETICS. 

lower jaw forward and to draw the tongue outward with forceps 
or the fingers. Finally, respiratory failure may result from the 
direct action of the a?iesthetic on the respiratory center. Should 
such an accident occur, the method of treatment to pursue is 
as follows : Withdraw the ether ; lower the head and elevate 
the legs ; push the jaw forward and draw the tongue outward ; 
and practice artificial respiration, persisting in it, if necessary, 
for at least half an hour. If the pulse is also weak, atropin 
and strychnin should be given hypodermically, but not alcohol, 
as its action closely resembles that of ether. 

Sudden heart-failure is a much less common accident under 
ether than asphyxia. It calls for lowering of the head, hypo- 
dermic injections of strychnin, caffein, and atropin, rhythmic 
compression of the precordium, and artificial respiration. The 
last serves to remove the ether from the chest, favors the en- 
trance of fresh air, and stimulates the circulation. 

After-effects. — The most common after-effects are nausea 
and vomiting. The administration of oxygen with the anes- 
thetic will often prevent their occurrence. The inhalation of 
vinegar immediately after the withdrawal of the ether is also 
efficacious. Should the nausea persist, a hypodermic injection 
of morphin and the administration of cracked ice with a little 
brandy, or of bismuth subnitrate with cerium oxalate, will 
usually suffice to allay it. 

Pneumonia is an occasional sequel. It has been ascribed 
to exposure of the patient, to chilling of the lungs by the 
rapid evaporation of the anesthetic, to the irritant action of the 
ether, to the accumulation of secretion in the bronchi, and, 
finally, to the lowered vitality of the tissues induced by pro- 
longed etherization. 

Paralysis. — Central paralysis from hemorrhage or embolism 
is rare. Peripheral palsies are not infrequent, and are due to 
compression of nerve-trunks. The anesthetic contributes only 
indirectly to the latter by rendering the patient oblivious to pain. 

Contraindications. — The contraindications to the employ- 
ment of ether as an anesthetic are advanced arteriosclerosis, 
acute inflammatory infections of the respiratory tract, severe 
nephritis, especially when associated with cardiovascular 
lesions, and anemia when the hemoglobin is less than 30 
per cent. The presence of valvular disease is not in itself 
a contraindication, provided compensation is well maintained. 
Diabetes, especially when well established and associated with 
acetonuria, should be considered a contraindication, since it has 
been shown that the anesthetic increases the acetone and 
renders the patient more liable to coma. 



CHL OR O FOR MUM. 1 2 3 

Other Uses of Ether. — Ether may be employed in the form 
of a spray to induce local anesthesia preliminary to opening 
small abscesses or performing paracentesis. 

Administered hypodermically (15-30 min. — 1.0-2.0 c.c), it 
has long enjoyed a reputation as a diffusible stimulant in collapse 
resulting from poisoning, acute infections, and diseases of the 
heart itself. 

It has been used internally as an anthelmintic against tape- 
worms and as a carminative in various forms of colic. 

To allay its irritant effect on the fauces it is best given in 
capsules or in ice-water. 

CHLOROFORMUM, U. S. P. 

(Chloroform, Chloroformum Purificatum, CHC1 3 .) 

Chloroform is a heavy, colorless, non-inflammable liquid, 
obtained by the action of chlorin on alcohol. It is soluble 
in two hundred times its volume of water, and in all propor- 
tions in alcohol, oils, and ether. The dose is 5-30 min. (0.3- 
2.0 c.c). 

Preparations. Dose. 

Aqua Chloroformi, U. S. P $-1 fl. oz. (15.0-30.0 c.c). 

Emulsum Chloroformi, U. S. P. (4 parts 

of chloroform in 100) ........ 1-4 fl. dr. (4.0-15.0 c.c. ). 

Linimentum Chloroformi, U. S. P., 

Spiritus Chloroformi, U. S. P 20-60 min. (1.0-4.0 c.c). 

Physiologic Action. — Chloroform has much the same 
action as ether. Like the latter, it produces, when freely in- 
haled, a set of phenomena which may be divided into three 
stages : The first stage is characterized by excitement, reflex 
effects (coughing, salivation, etc.), mydriasis, irregular breathing, 
acceleration of the pulse, loss of self-control, muscular rigidity, 
and imperfect consciousness ; the second, by complete uncon- 
sciousness, muscular relaxation, loss of reflexes, moderate con- 
traction of the pupils, regular shallow breathing, fall of blood- 
pressure, and fall of temperature ; and the third y by symptoms 
of cardiac and bulbar paralysis — pallor, dilatation of the pupils, 
feeble irregular breathing, extreme weakness of the pulse, and 
very low temperature. 

Circulatory System. — Anesthesia induced by chloroform is 
always accompanied by a distinct lowering of the blood- 
pressure. This effect is mainly due to depression of the heart 
muscle, but partly also to dilatation of the blood-vessels from 
depression of the vasomotor center. Death from chloroform 
may occur at the very beginning of the anesthesia from in- 



124 GENERAL ANESTHETICS. 

tense reflex stimulation of the inhibitory cardiac center, aided, 
no doubt, by the weakening effect of the drug on the heart 
muscle itself. Such sudden arrest of the organ is more likely 
to occur when the vapor is administered in too concentrated 
form. 

Respiratory System. — In large amounts chloroform acts as 
a respiratory paralyzant. It depresses the respiratory center 
not only directly but also indirectly by lowering the blood- 
pressure in the medulla. 

Nervous System. — The action of chloroform on the central 
nervous system is marked by a progressive paralysis involving 
successively the cerebrum, the spinal cord, and the medulla. 
As in the case of ether, the sensory neurons appear to be 
affected before the motor. To produce complete anesthesia the 
inspired air must contain not less than 1.5 to 2 volumes per 
cent, of the vapor. 

Temperature. — In prolonged anesthesia there is a very pro- 
nounced fall in the body temperature, due in part to increased 
loss of heat from dilatation of the cutaneous vessels and in part 
to decreased production of heat from the absence of muscular 
movements. 

Nutrition. — Prolonged chloroform administration increases 
the output of nitrogen, phosphates, and sulphates in the urine, 
and produces fatty degeneration of the various organs, especially 
of the liver, heart, and kidneys. Degenerative changes in the 
cardiac ganglia have also been described. 

Alimentary Canal. — Taken internally in small quantities, 
chloroform produces a sense of warmth in the stomach, in- 
creases peristaltic movements, and aids in the expulsion of flatus. 

Local Action. — When applied to the skin, it evaporates 
rapidly and produces a sense of coldness. When evaporation 
is prevented, it causes redness of the surface and even vesication. 

Lower Organisms. — Even in dilute solution chloroform is 
destructive to many of the lower forms of animal and vegetable 
life. 

Cause of Death Under Chloroform. — When the vapor 
is administered in too concentrated form death may occur sud- 
denly at the very beginning of the anesthesia from reflex arrest 
of the heart. Even with comparatively dilute vapor death may 
occur late in the anesthesia from failure of the heart or failure 
of the respiration, largely aided by the marked fall of blood- 
pressure. Again, death may occur in from twelve hours to 
three or four days after the operation (delayed chloroform- 
poisoning) from a toxemia induced by degenerative changes in 
the liver. In some of these cases the symptoms closely re- 



CJIL OR O FOR MUM. 1 2 5 

semble those of acute yellow atrophy of the liver, and in others 
the condition appears to be one of acidemia, with acetonuria, 
vomiting, restlessness, delirium, Cheyne-Stokes breathing, and 
coma as its chief manifestations. 

The Actions of Chloroform and Ether Compared. — 
Chloroform is a much more powerful anesthetic than ether. 
Quantity for quantity, it is more irritating than ether, but being 
administered in less concentrated form than the latter, it is 
more agreeable to the patient and is less productive of cough- 
ing and choking. The toxic effect of chloroform on the circu- 
lation is much greater than that of ether, and the margin of 
safety between the amount required to induce anesthesia and 
that which causes death is much narrower with chloroform 
than with ether. Sudden death from intense vagal stimulation, 
which is not very rare under chloroform, is never observed 
under ether. Unpleasant sequelae (nausea, vomiting, hyper- 
secretion of saliva and bronchial mucus) are more pronounced 
after ether than chloroform anesthesia ; on the other hand, 
serious metabolic changes (fatty degeneration of the liver, 
heart, etc.) are far more likely to result from the administration 
of chloroform than of ether. Finally, the mortality from chlo- 
roformization appears to be at least three times that from ether- 
ization. 

Therapeutics. — Chloroform is employed as a general an- 
esthetic, as a nerve sedative, a carminative, an anthelmintic, and 
a counterirritant. 

General Anesthetic. — The precautions to be observed in 
administering chloroform as an anesthetic are much the same 
as those already described in dealing with ether. The vapor, 
however, must never be concentrated, but' well mixed with air. 
A number of special devices for regulating the strength of the 
vapor have been recommended, but it is doubtful whether any 
of these offers any great advantage over the ordinary mask or 
folded towel in the hands of a skilled anesthetist. If the mask 
or towel be employed it should not be brought closer to the 
face than two inches, even after the patient has become accus- 
tomed to the anesthetic. If struggling occurs or the breath 
be held the distance should be increased, as the following inspi- 
rations will of necessity be unusually deep. The drug is best 
delivered drop by drop, at a rate never exceeding 60 drops 
per minute. Regular snoring breathing, muscular relaxation, 
and loss of the eye reflexes indicate complete anesthesia. An 
ordinary operation will not usually require more than an ounce 
or two of chloroform. The anesthetist should not rely upon any 
one sign as a warning of danger, but should keep careful watch 



126 GENERAL ANESTHETICS. 

on the face, the respiration, and the pulse. Lividity of the 
face, irregular gasping respiration, feebleness of the pulse, or 
sudden pupillary dilatation (unless accompanied by signs of 
returning consciousness) call for immediate withdrawal of the 
anesthetic, lowering of the head, practice of artificial respira- 
tion, and the hypodermic administration of cardiac stimulants, 
such as ammonia, strychnin, caffein, and digitalis, or the injec- 
tion of adrenalin (1-2 c.c. of 1 : 1000 solution) in salt solution 
into an artery (radial), toward the heart (Crile). Massage of 
the heart through the diaphragm, when operating on the 
abdomen, has also been recommended. In sudden arrest of 
the heart from excessive inhibition at the beginning of anes- 
thesia, the injection of atropin in large dose should be included 
among the restorative measures. 

When chloroform is administered in the presence of lighted 
gas-jets, the room should be well ventilated, since the burnt 
vapor of the anesthetic yields irritant products (especially car- 
bonyl chloride) capable of inducing pneumonia when inhaled 
in concentrated form. 

Conditions Favoring- the Use of Chloroform as an 
Anesthetic. — While chloroform is ordinarily more dangerous 
than ether, it is to be preferred to the latter when the patient 
is suffering from an acute inflammation of the respiratory tract 
or advanced nephritis ; when it is desired merely to lessen the 
excitability of the nervous system, as in checking convulsions 
or to dull intense pain, as in labor or biliary colic ; when very 
complete muscular relaxation is required, as in the reduction 
of certain luxations ; and when the actual cautery is to be 
applied. 

In very hot climates chloroform is generally preferred to 
ether, because the latter is so very volatile that there is diffi- 
culty in maintaining complete anesthesia with it. In military 
practice also chloroform is preferable on account of the rapidity 
of its action and the small quantity required to induce insen- 
sibility. 

Contraindications to Chloroform Anesthesia. — Chloro- 
form is particularly to be avoided in all conditions of heart 
weakness ; in all operations likely to be attended by profuse 
hemorrhage ; in operations requiring the sitting posture, and 
in very prolonged operations. 

Nerve-sedative. — A few whiffs of chloroform may be 
employed to allay motor excitation in puerperal eclampsia, 
tetanus, and chorea insaniens, and to allay local spasm in 
asthma, whooping-cough, aud severe attacks of renal and 
biliary colic. 



NITROUS OXID. 127 

In attacks of angina pectoris of great intensity Balfour and 
Osier recommend inhalations of chloroform. It may be 
dropped upon a handkerchief, or, as Balfour recommends, 
poured on a sponge in a smelling-bottle, and the patient told 
to breathe it through the nose as deeply as possible. In a 
minute or two relief is obtained. 

In the obstinate cough 0$ phthisis the addition of chloroform 
to the usual cough-mixture is often advantageous. 

U Codeinse sulphatis, gr. iv. (0.26 gm.); 

Acidi hydrocyanici diluti, TT^ xl (2.5 c.c.) ; 

Spiritus chloroformi, f^ij (8.0 c.c.) ; 

Glycerini, fjfss (15.0 c.c.) ; 

Elixiris aurantii, q. s. ad f^iij (90.0 c.c). — M. 
Dose. One teaspoonful. 

Carminative. — It is a useful carminative and sedative in 
gastralgia and intestinal colic. The following combination 
will be found useful in gastralgia: 

R Chloroformi, %iss-ij (5.5-8.0 c.c.) ; 

Spiritus ammoniae aromatici, 
Spiritus vini gallici, 

Tincturae cardamomi composite, aa fgv (18.0 c.c.).— M. 
Sig. A teaspoonful in hot water every fifteen or thirty minutes until relief is 
obtained. 

Anthelmintic. — It has been used in large doses .(fgss-j — 
2.0-4.0 c.c.) as an anthelmintic against tapeworms, but it is an 
unreliable remedy. In nineteen cases reported by Whyte and 
Leichtenstern it proved successful in only two instances. 

Counterirritant. — In the form of a liniment chloroform is 
extensively used as a stimulating application in muscular rheu- 
matism, sprains, and contusions. 

NITROUS OXID. 

(Nitrogen Monoxid, N 2 0.) 

Nitrous oxid is obtained from the distillation of ammonium 
nitrate, and appears as a colorless, odorless gas having a 
somewhat sweetish taste. By pressure it is converted into a 
liquid, and in this form is stored in iron cylinders for subse- 
quent use. 

Physiologic Action. — When freely inhaled, undiluted 
nitrous oxid causes an increase of blood-pressure, a sense of 
exhilaration, ringing in the ears, and lividity of the face ; in a 
minute or two these symptoms are followed by complete un- 
consciousness. Upon the withdrawal of the anesthetic recov- 



128 GENERAL ANESTHETICS. 

ery ensues in from thirty to sixty seconds. Great excitement, 
laughter, or a disposition to fight is frequently induced by 
inhalation of the gas when the supply of air is not completely 
cut off. 

Nitrous oxid anesthesia, as ordinarily induced, is caused in 
part by the specific action of the gas on the cerebrum, and in 
part by the asphyxia resulting from the exclusion of oxygen 
from the lungs. According to the researches of Wood and 
Kemp, the gas has no direct action on the heart or vasomotor 
center, the increased blood-pressure being due to asphyxia. 
Nitrous oxid is the safest of the general anesthetics, and, 
moreover, its use is not followed by any unpleasant after- 
effects. Hewitt was able to find records of but seventeen 
deaths from its administration between the years i860 and 
1900. 

Therapeutics. — As an anesthetic, nitrous oxid is especially 
suitable for minor operations requiring but a short period of 
unconsciousness. By diluting the gas with sufficient oxygen 
(20 per cent.) to prevent asphyxia, and administering the mix- 
ture under a pressure of one and one-quarter atmospheres, to 
secure free absorption, narcosis can be induced in a minute or 
two, and maintained almost indefinitely. Anesthesia induced 
in this way has frequently been employed in operations lasting 
from thirty minutes to an hour. The disadvantages of nitrous 
oxid for lengthy operations are the cumbersome apparatus 
required for its administration and the large quantity of gas 
needed (200 gallons per hour) for maintaining the anesthesia. 

^BTHYLIS BROMIDUM. 

(Ethyl Bromid ; Hydrobromic Ether, C 2 H 5 Br.) 

Ethyl bromid is obtained by the distillation of a mixture of 
ethyl alcohol, sulphuric acid, and potassium bromid. When 
perfectly pure it forms a colorless, highly volatile, inflammable 
liquid, having a sweetish taste and a chloroformic odor. On 
exposure to air it liberates bromin and hydrobromic acid and 
becomes unfit for use. It should be kept in dark amber- 
colored, well-stoppered bottles. It must not be confounded 
with the poisonous ethylene bromid. 

Physiologic Action and Therapeutics. — Ethyl bromid 
somewhat resembles chloroform in its anesthetic properties, 
but it acts more quickly, is inhaled with even less difficulty, is 
less depressing, and its effects are less lasting. Large doses 
depress the respiration and lower arterial pressure. After its 
administration there is a garlicky odor on the breath which 



&THYLIS CHLORIDUM. 1 29 

may persist for a day or two. With this exception it rarely 
causes disagreeable after-effects, such as headache, nausea, 
and vomiting Although its use is not entirely devoid of 
danger, there is good reason for believing that with a pure 
preparation, cautiously administered, the risk is very little 
greater than with ether. While not quite so safe as nitrous 
oxid, it has the advantage of not requiring cumbersome appa- 
ratus for its administration. 

Ethyl bromid is a useful anesthetic for short operations. 
The dose for a child is from 1-3 drams (4-1 1 c.c), and for an 
adult, from 2-6 drams (8-22 c.c). The patient should be 
instructed to breathe deeply ; the full dose should be poured 
at once upon the inhaler (preferably a towel folded into an 
air-tight cone), and the inhaler should be held firmly over the 
nose and mouth, and not removed until the anesthesia is com- 
plete. Anesthetization is usually accomplished within from 
thirty to forty seconds, and lasts from two to three min- 
utes. It is not safe to continue the administration for more 
than two minutes, and under no circumstances should the 
anesthesia be prolonged by removing the mask and adding 
more of the drug. 

The contraindications are severe lesions of the heart, lungs, 
or kidneys. 

iETHYLIS CHLORIDUM, U. S. P. 

(Ethyl Chlorid, C 2 H 5 C1. ) 

Ethyl chlorid is prepared by the action of hydrochloric acid 
gas upon absolute ethyl alcohol, the hydroxl group in the 
latter being replaced by chlorin. It is a colorless, highly vola- 
tile liquid, having an odor resembling that of chloroform and 
a burning taste. As its vapor is very inflammable, it should 
not be used in proximity to a gas-flame or fire. 

Physiologic Action and Therapeutics. — Ethyl chlorid 
is a fugaAous general anesthetic. Accompanying the anes- 
thesia the%; is_ajall of arterial pressure and a decrease in the 
pulse- rate, due probably Vi |o direct cardiac action. The vapor 
should be administered weffctoixed with air, preferably from a 
special apparatus, such as that devised by Apperson. The 
inhaler is fitted to the face in the usual way and the patient is 
instructed to breathe naturally. Anesthesia, as a rule, is 
accomplished in from one to three minutes, from 1 to 2 fluid- 
drachms (4.0-8.0 c.c.) of the drug being required for the pur- 
pose. Recovery is usually complete in from two to five 
minutes. 

As a general anesthetic, ethyl chlorid is only suited for brief 



1 30 ANTICONVULSANTS. 

surgical operations. Its action is rapid, is not attended by irri- 
tation of the respiratory mucous membrane, choking sensa- 
tion, or cyanosis, and is rarely followed by nausea or vomiting; 
complete muscular relaxation, however, is not obtained. It 
has an advantage over nitrous oxid in not requiring cumber- 
some apparatus for its administration and in producing a 
longer narcosis, and over ethyl bromid in not leaving an offen- 
sive garlicky odor on the breath. The relative safety of ethyl 
chlorid remains to be determined. Quite a number of fatal 
accidents from its use, however, have already been reported. 
The future will probably accord it a place below that of chloro- 
form. 

On account of the intense cold caused by its rapid evapora- 
tion, ethyl chlorid is frequently employed as a local anesthetic 
in minor operations. 



GENERAL ANALGESICS OR ANODYNES. 

General analgesics or anodynes are remedies which relieve 
pain without necessarily inducing unconsciousness or general 
anesthesia. They accomplish their object by depressing the 
sensory side of the central nervous system. The most power- 
ful analgesic is opium. While it has the power of relieving 
pain arising from almost any cause, it is especially useful in 
pain occasioned by gross lesions — inflammation, traumatism, 
and morbid growths. In the various so-called functional pains, 
such as headache and neuralgia, the coal-tar derivatives — anti- 
pyrin, phenaceti?i, and acetanilid — are more serviceable anal- 
gesics. The manner of their action is not definitely known, 
but they probably act upon the perceptive centers in the brain. 
Camiabis indica somewhat resembles opium in its action as an 
analgesic, but it is far less powerful. It is especially useful in 
neuralgia and migraine. The bromids, by depressing the cere- 
bral cortex, often afford relief in headache, but in other forms 
of pain they usually fail. Some drugs seem to have an affinity 
for certain nerves : thus, gelsemium and butyl chloral hydrate 
are often distinctly valuable in trifacial neuralgia. 



ANTICONVULSANTS. 

Certain drugs have the power of controlling cerebral con- 
vulsions by directly diminishing the excitability of the motor 
area in the cortex of the brain. A drug that thus depresses 
the motor centers, and also lessens the power of the motor 



A NTISPA SMODICS. 1 3 I 

side of the spinal cord to convey discharges from the brain to 
the muscles, or lessens the power of the sensory side of the 
spinal cord to transmit to the brain stimuli from without, has 
additional value as an anticonvulsant. 

Anesthetics (ether and chloroform) profoundly affect the brain 
and spinal cord, first depressing the sensory parts and then the 
motor. They are especially useful in severe convulsions, such 
as may occur in hysteria, puerperal eclampsia, and the status 
epilepticus. Bromids also depress the brain and the spinal 
cord. While their action is not so powerful as that of the 
anesthetics, it is much more permanent. They are very useful 
in epilepsy and in the reflex convulsions of childhood. Chloral 
appears to have more influence on motor activity than the bro- 
mids, and is especially useful in convulsions of spinal origin, 
such as those of strychnin-poisoning and tetanus, although it 
may be employed with advantage also in uremic, infantile, and 
puerperal convulsions. It is too depressing for continuous use 
in essential epilepsy. Antipyrin and Solanum Carolinense (horse- 
nettle) are of some value in essential epilepsy, but the manner 
in which they act is not definitely known. Amy I nitrite is of 
service in aborting threatened convulsions and in breaking up 
a series of seizures, such as occur in the status epilepticus. Its 
efficacy has been ascribed by some authorities to direct depres- 
sion of the central nervous system, and by others to dilatation 
of the arterioles of the brain. 



ANTISPASMODICS. 

Antispasmodics are remedies used to control minor grades 
of motor excitation and to lessen states of general nervous 
irritability. They vary in the manner of their action. Some, 
like hops and lactucarium, are feeble depressants of the nervous 
system, while others, like asafetida and valerian, probably owe 
what virtue they possess to the mental effect induced by their 
strong odor and taste. As a class, antispasmodics are useful 
in hysteria, nervous excitability, and local spasms. The follow- 
ing drugs are the most important members of this group: 

Camphor. Cimicifuga. 

Asafetida. Lactucarium. 

Valerian. Hops. 

Compound spirit of ether. Sumbul. 
Musk. Viburnum prunifolium. 

Oil of amber. 



I32 ANTISPA SMODICS. 

CAMPHORA, U. S. P. 

(Camphor, C 10 H l6 O.) 

Camphor is a whitish, translucent, volatile substance (solid 
volatile oil or stearopten), having a penetrating odor and a 
pungent taste, and obtained by distilling the wood of an 
Oriental tree — Cinnamomum Camphor a. It dissolves freely 
in all ordinary menstrua except water, in which it is only 
sparingly soluble. The dose is from 1-5 gr. (0.06-0.3 gm.). 

Preparations. Dose. 

Aqua Camphorae, U. S. P. (0.8 per cent.) . . \-\ fl. oz. (15.0-30.0 c.c.). 
Ceratum Camphorae, U. S. P. (10 per cent.). 
Linimentum Camphorae, U. S. P. (20 per 

cent, in cotton-seed oil). 
Linimentum Saponis, U. S. P. (4.5 per cent.). 
Spiritus Camphorae, U. S. P. (10 percent.) . 10-30 min. (0.6-2.0 c.c). 

It also enters into Tinctura opii camphorata. 

Physiologic Action. — In therapeutic doses camphor 
stimulates the higher cerebral centers, exerting a calmative 
influence in the presence of nervous irritability. It has a 
stimulating effect on the heart, although after large doses the 
blood-pressure falls, probably from paresis of the vasomotor 
center. In the stomach it acts as a mild carminative, inducing 
a sensation of warmth, increasing peristalsis, and expelling 
flatus. The action of camphor on the respiration has not been 
fully determined, but the researches of Stockman and Binz 
indicate that the drug is a stimulant to the respiratory center. 
Moderate doses exert a feeble anaphrodisiac effect. Applied 
externally it acts as a stimulant and antipruritic. When taken 
internally much of it is destroyed in the body, but a part is 
eliminated in the urine as camphoglycuric acid. 

Toxic doses of camphor produce languor, vertigo, headache, 
confusion of thought, tinnitus aurium, gastric irritation, a 
rapid, feeble pulse, convulsions, and collapse. The convul- 
sions are of an epileptiform character, and are due to the 
action of the drug on the cerebral cortex. 

Therapeutics. — Camphor is employed as an antispas- 
modic, a circulatory stimulant, carminative, and rubefacient. 

As an antispasmodic, it has been recommended in hysterical 
exciteme7it, hiccough, dysmenorrhea, who ping-cough, chordee, 
and the various climacteric neuroses. 

As a circulatory stimulant, camphor is exceedingly valuable 
in adynamic fevers, particularly in typhoid fever and pneu- 
monia. It not only serves to strengthen the pulse in these 
affections, but it also acts favorably in lessening the restless- 
ness and delirium. 



CAMPHOR A MONOBROMATA. I 33 

As a carminative, Camphor is serviceable in tympanites, 
intestinal colic, and the various forms of choleraic diarrhea. 

As a rubefacient, it is much used in the form of a liniment 
in sprains, bruises, and muscular rheumatism. Anderson's 
powder is a useful antipruritic dusting-powder in simple 
erythe7na, intertrigo, and urticaria. It consists of from 1-2 
drams (4.0-8.0 gm.) of finely pulverized camphor to \ ounce 
(15.0 gm.) each of powdered starch and zinc oxid. 

Camphor is a useful remedy in acute coryza, particularly 
when it is given early in the attack. It may be used internally 
and also by inhalation, a teaspoonful of powdered camphor 
being added to a tumbler of boiling water, and the fumes 
inhaled. 

Administration. — Camphor may be given internally in 
the form of the water or spirit, or in substance in pill or cap- 
sule. In adynamic fevers it is best given subcutaneously dis- 
solved in sterilized olive oil. From 1-2 gr. (0.06-0.13 gm.) 
may be dissolved in 15 min. (1.0 c.c.) of the oil, and injected 
every three or four hours, or even every two hours when the 
symptoms are very urgent. In coryza the following combina- 
tion may be employed : 

Jk Pulveris opii, gr. iij-vj (0.2-0.4 gm.) ; 

Pulveris camphorse, gr. xij (0.8 gm.) ; 

Ammonii carbonatis, gr. xxiv-xxxvj (1.5-2.3 gm. ). — M. 

Fiant capsulae No. xii. 
Sig. One every three hours. 

Incompatibles. — Liquefaction results when camphor is 
triturated with chloral hydrate, menthol, phenol, or thymol. 
Aqueous solutions precipitate camphor from its alcoholic solu- 
tion. 

CAMPHORA MONOBROMATA, U. S. P. 

(Monobromated Camphor, C 10 H, 5 BrO.) 

Monobromated camphor is obtained from the union of 
bromin and camphor in the presence of heat, and occurs as 
colorless prismatic needles or scales, having a mild cam- 
phoraceous odor and taste. It is very sparingly soluble in 
water and glycerin, but freely soluble in alcohol, ether, and 
chloroform. The dose is from 2-5 gr. (0.13-0.3 gm.)in pill or 
capsule. 

Physiologic Action. — In small doses it acts as a sedative 
to the nervous system. Toxic doses are followed by tremors, 
muscular relaxation, a marked slowing of the pulse, embar- 
rassed respiration, epileptiform convulsions, and coma. 



1 34 ANTISPASMODICS. 

Therapeutics. — Monobromated camphor is employed as 
an antispasmodic and anaphrodisiac. It has been recom- 
mended in hysteria, delirium tremens, chorea, and whooping- 
cough, but its use in these affections is only rarely attended 
with success. In petit mal it is sometimes more effective than 
the ordinary bromids. Its more important use is as an 
anaphrodisiac. It often proves very efficacious in abnormal 
sexual excitement, chordee, spermatorrhea, etc. Its chief draw- 
back is its tendency to induce heartburn and eructations. In 
spermatorrhea it may be combined with hyoscin, as in the fol- 
lowing formula : 

H; Hyoscinae hydrobromidi, gr. T ^ (0.006 gm.) ; 

Camphorae monobromatae, £} (4.0 gm.). — M. 
Fiant pilulae No. xx. 
Sig. One or two at bedtime. 

ASAFCETIDA, U. S. P. 

(Asafetida.) 

Asafetida is a gum-resin obtained by incising the roots of 
Ferula fcetida, an umbelliferous plant abounding in Persia 
and Afghanistan. It appears in the form of irregular masses 
or tears of a yellowish-brown color, and has a persistent 
garlicky odor and an acrid taste. It consists of gum, resin, 
and an essential oil (about 4 per cent.) which is rich in sulphur. 
The oil is the most active ingredient. The dose is from 3-10 
gr. (0.2-0.65 gm.). 

Preparations. Dose. 

Emulsum Asafoetidae, U. S. P. (4 per cent. 

watery emulsion) £-1 fl. oz. (i 5.0-30.0 c.c.). 

Tinctura Asafcetidae, U. S. P |-i fl. dr. (2.0-4.0 c.c.). 

Pilulae Asafoetidae, U. S. P. (3 gr.— 0.2 gm.) 1-3 pills. 

Physiologic Action. — On the circulatory and nervous 
systems asafetida acts as a feeble stimulant ; on the alimentary 
canal, as a carminative. 

Therapeutics. — Asafetida is employed chiefly as an anti- 
spasmodic and as a carminative. As an antispasmodic it is 
used in nervous excitement, whooping-cough, and hysteria. Sup- 
positories of asafetida are sometimes valuable in infantile con- 
vulsions and in the restlessness of the specific fevers. As a 
carminative, it is an excellent remedy in infantile colic and the 
flatident dyspepsia of the aged. An enema of asafetida is one 
of the most efficacious remedies that we possess in excessive 
tympanites. Asafetida has also been employed as a stimulating 
expectorant in chronic bronchitis. 



VALERIANA. 1 35 

Administration. — For continued use the drug is best 
administered in the form of pills. To children it may be con- 
veniently administered in the form of suppositories. In tym- 
panites the official emulsion (4-6 ounces — 120.O-175.O c.c.) 
should be employed as an enema. 

VALERIANA, U. S. P. 

(Valerian.) 

Valerian is the rhizome and roots of Valeriana officinalis, a 
native of Europe. Its active principles are a volatile oil and 
valeric acid. 

Preparations. Dose. 

Tinctura Valerianae, U. S. P 1-2 fl. dr. (4.0-8.0 c.c. ). 

Tinctura Valerianae Ammoniata, U. S. P. 

(made by macerating valerian in aromatic 

spirts of ammonia) 1-2 fl. dr. (4.0-8.0 c.c. ). 

Fmidextractum Valeriance, U. S. P. ... |-i fl. dr. (2.0-4.0 c.c). 

Physiologic Action. — In moderate doses valerian has a 
slight stimulant effect on the central nervous system, especially 
the cerebrum, and on the circulation. Very large doses pro- 
duce a sense of warmth in the stomach, quickening of the 
pulse, vomiting, diarrhea, frequent micturition, headache, ver- 
tigo, and hallucinations. 

Therapeutics. — Valerian is a valuable remedy for subdu- 
ing the various nervous phenomena occurring in patients 
of excitable temperaments. The spasms, headache, palpita- 
tion, globus, sleeplessness, and flatulent distention of hysteria 
are often remarkably influenced by the drug. 

AMMONII VALERAS, U. S. P. 

(Ammonium Valerate ; Ammonium Valerianate, NH 4 C 5 H 9 2 .) 

Valerate of ammonia occurs in the form of colorless quad- 
rangular plates having the odor of valeric acid and a sharp, 
sweetish taste. It is freely soluble in water and alcohol. Its 
dose is from 5-10 gr. (0.3-0.6 gm.) in the form of an elixir. 

It is employed for the same purposes as valerian. 

FERRI VALERAS. 

(Iron Valerate; Iron Valerianate, Fe 2 (C 5 H 9 2 ) 6 .) 

Iron valerate appears as a dark-red amorphous powder, 
having the odor of valeric acid. It is a useful combination of 
an antispasmodic with a chalybeate, and may be prescribed 
with advantage in anemia, associated with nervous excitement 



1 36 ANTISPASMODICS. 

or hysteria. The dose is from 1-3 gr. (0.06-0.2 gm.) in pill 
form. The following tonic and antispasmodic pill of three 
valerates is frequently prescribed : 

R Ferri valeratis, 
Zinci valeratis, 

Quininae valeratis, aa gr. xx (1.3 gm.). — M. 

Fiant pilulae No. xx. 
Sig. One after meals. 

ZINCI VALERAS, U. S. P. 

(Zinc Valerate ; Zinc Valerianate, Zn(C 5 H 9 2 ) 2 + H 2 0.) 

Zinc valerate appears in the form of white, pearly scales,, 
having the odor of valeric acid, and a sweetish, astringent, 
and metallic taste. It is soluble in 100 parts of water and 40 
parts of alcohol. The dose is from \- 3 gr. (0.03-0.2 gm.). 

It has about the same therapeutic value as valerian. 

SPIRITUS iETHERIS COMPOSITUS, U. S. P. 

(Compound Spirit of Ether ; Hoffmann's Anodyne.) 

Hoffmann's anodyne is a colorless, inflammable liquid, hav- 
ing an ethereal odor and taste. It consists of 325 parts by 
volume of ether, 650 parts of alcohol, and 25 parts of ethereal 
oil, the last being an ethereal solution of the product of the dis- 
tillation of sulphuric acid and alcohol. The dose is from J-2 
fl. dr. (2.0-8.0 ex.). 

Physiologic Action and Therapeutics. — Hare con- 
cludes, from a careful study of this compound, that its calma- 
tive effects are largely due to the ether which it contains 
rather than to the ethereal oil, and that each of its ingredients 
stimulates the system — the ether the most, and the ethereal 
oil the least powerfully. 

Hoffmann's anodyne is an excellent carminative for ex- 
pelling gas from the stomach. It affords prompt relief 
in severe paroxysmal palpitation dependent upon gastric 
flatulence. It is often of service in angina pectoris, especially 
when the attacks are precipitated by flatulency. In chronic 
valvular disease, when compensation is partially lost and the 
patient suffers from restlessness, dyspnea, and insomnia, the 
compound spirit of ether often acts most favorably. It is 
sometimes very efficacious in hiccough. A combination like 
the following will be found useful in asthma : 

R Ammonii bromidi, gij (8.0 gm.) ; 

Tincturse belladonnse, fgj (4.0 cc.) ; 

Tincturse lobeliae, f|[ij (8.0 cc.) ; 

Spiritus setheris compositi, f^j (30.0 cc.) ; 

Elixiris aromatici, q. s. ad f§iij (90.0 cc). — M. 

Sig. A dessertspoonful in water every hour or two during the paroxysm. 



CIMICIFUGA. I37 

The following mixture is often serviceable in severe gastric 
flatulency : 

R Spiritus setheris compositi, 

Spiritus camphorse, aa £ss (2.0 c.c.) ; 

Spiritus menthas piperita, fr\vj (0.4 c.c). — M. 

Sig. To be taken in water. 

MOSCHUS, U. S. P. 

(Musk.) 

Musk is the dried secretion from the preputial follicles of 
Moschus moschiferus, a species of deer found in Central Asia. 
It appears as reddish-black unctuous grains having a peculiar 
penetrating odor and a bitter aromatic taste. The dose is 
from 5-15 gr. (0.3-1.0 gm.), given preferably by the rectum, 
in suppository or suspended in mucilage. 

Preparation. Dose. 

Tinctura Moschi, U. S. P. (5 per cent.) . 1-2 fl. dr. (4.0-8.0 c.c). 

Therapeutics. — Musk is used as an antispasmodic and as 
a general stimulant. As Graves first pointed out, it is a most 
valuable stimulant in typhoid fever and kindred affections, 
when there are profound nervous exhaustion and circulatory 
failure. It is also of service in obstinate hiccough, the convul- 
sions of childhood, and laryngismus stridulus. The great draw- 
backs to its use are its costliness and the difficulty in obtaining 
an unadulterated preparation. 

CIMICIFUGA, U. S. P. 

(Black Snakeroot, Actaea Racemosa.) 

Cimicifuga is the dried rhizome and rootlets of Cimicifuga 
racemosa, a perennial plant growing in the woodlands of North 
America. It contains a resin, a bitter neutral substance, and a 
volatile oil. 

Preparations. Dose. 

Tinctura Cimicifugae, U. S. P £-2 fl. dr. (2.0-8.0 c.c). 

Fluidextractum Cimicifugse, U. S. P. . . . 10-30 min. (0.6-2.0 c.c). 

Extractum Cimicifugse, U. S. P 2-8 gr. (0.1-0.5 g m 0- 

Physiologic Action. — In large doses cimicifuga causes 
nausea, headache, vertigo, tremors, muscular relaxation, 
slowing and weakening of the pulse, anesthesia, and, finally, 
paralysis of respiration. The anesthesia is due, according to 
Hutchinson, to paralysis of the sensory side of the spinal cord. 
The weakness of the pulse is probably due to a direct depres- 
sant effect exerted on the heart itself. In full doses it seems 
also to possess the power of stimulating uterine contractions. 

Therapeutics. — Cimicifuga is a valuable remedy in simple 



1 3 8 ANTISPA SMODICS. 

chorea, ranking next to arsenic in efficiency. It should be given 
in doses of 10 min. (0.6 c.c.) of the fluid extract three times a 
day, after meals, and gradually increased to from ^— 1 dr. (2.0- 
4.0 c.c). It is sometimes of service in chronic rheumatic 
affections of the nerves and muscles, like myalgia, pleurodynia, 
sciatica, and lumbago, but in articular rheumatism it is of little 
value. It is said to be useful in atonic amenorrhea, menor- 
rhagia, and sudden cessation of the menses from cold or nervous 
shock. It has been used in labor to stimulate uterine con- 
tractions, its action resembling that of quinin rather than that 
of ergot. Ringer strongly recommends it in combination 
with gelsemium for the distressing symptoms attending the 
menopause ; and, according to Simpson, it is highly beneficial 
in the mental disturbances which sometimes follow pregnancy. 
It is often of distinct service in relieving the tinnitus aurium 
accompanying chronic catarrh of the middle ear. It has been 
used as an expectorant in bronchitis, with free expectoration, 
and in phthisis. 

LACTUCARIUM, U. S. P. 

(Wild Lettuce.) 

Lactucarium is the concrete milk-juice of Lactuca virosa, 
a biennial herb cultivated chiefly in Central and Southern 
Europe. It contains lactucin (a bitter principle), lactucic acid, 
lactucopicrin, and lactucerin. The dose is from -|-i dr. (2.0- 
4.0 gm.). 

Preparations. Dose. 

Tinctura Lactucarii, U. S. P \-\ A. dr. (2.0-4.0 c.c). 

Syrupus Lactucarii, U. S. P 1-4 fl. dr. (4.0-15.0 c.c). 

Fluidextractum Lactucarii 20-30 min. (1.2-2.0 c.c). 

Therapeutics. — Lactucarium is a feeble hypnotic, an ano- 
dyne, and an antispasmodic. Added to cough-mixtures, the 
syrup is a useful sedative in the acute bronchitis of children. 

HUMULUS, U. S. P. 

(Hops.) 

Hops are the dried strobiles of Humulus Lupulus, a perennial 
climber largely cultivated in Europe and the United States. 
They have an aromatic odor, and a bitter, slightly astringent 
taste. A glandular powder separated from the dried strobiles 
is also official as Lupulinum (lupulin). Lupulin, of which hops 
contain from 8 to 15 per cent., appears in the form of minute 



SUMBUL. I39 

yellowish-brown, resinous granules, having a bitter aromatic 
taste. The chief constituents of hops are cholin (a volatile, 
liquid alkaloid), a volatile oil, lupamaric acid (the bitter prin- 
ciple), tannic acid, and a resin. The dose of lupulin is from 
5-15 gr. (0.3-1.0 gm.). 

Preparations. Dose. 

Tinctura Humuli, |— 2 fl. dr. (2.0-8.0 c.c). 

Fluidextractum Lupulini, U. S. P 5 -30 m in. (0.3-2.0 c.c). 

Oleoresina Lupulini, U, S. P 2-5 gr. (0.13-0.3 gm.). 

Therapeutics.— Hops act as a bitter tonic and as a feeble 
hypnotic. In the restlessness of fevers and in delirium tremens 
they are sometimes useful sedatives. They have been found 
especially serviceable in chordee, spermatorrhea, and vesical 
irritation. The following suppositories, containing lupulin, 
afford relief in chordee : 

R Pulveris opii, gr. vj (0.4 gm.) ; 

Pulveris camphorae, gr. xxiv (1.5 gm.); 

Lupulini, 3J(4-ogm.); 

Olei theobromatis, q. s. — M. 

Fiant suppositoria No. vi. 
Sig. Introduce one into the bowel at bedtime. 



SUMBUL, U. S. P. 

(Musk-root.) 

Sumbul is the root of Ferida Sumbul t a perennial herb grow- 
ing in Central Asia. Its chief constituents are a resin, to which 
its musk-like odor is due, a fixed oil, angelic acid (sumbulic 
acid), and valerianic acid. The dose of the root is from 10-30 
gr. (0.6-2.0 gm.). 

Preparations. Dose. 

Fluidextractum Sumbul, U. S. P ^-1 fl. dr. (2.0-4.0 c.c). 

Extractum Sumbul, U. S. P 2-5 gr. (0.1-0.3 gm.). 

Therapeutics. — Sumbul is sometimes useful as an anti- 
spasmodic in hysteria and allied neuroses. In neurastJienia 
the extract may be given in pill with iron and arsenic. The 
following combination, suggested by Bradbury, is very effect- 
ive in relieving the insomnia, mental depression, and flushing 
heats commonly occurring at the menopause : 

R Ammonii bromidi, ^ij(8.ogm.); 

Fluidextracti sumbul, 

Tincturse humuli, aa f^iss (45.0 c.c.) ; 

Spiritus camphorae, f£iij (ll.o c.c.) ; 

Elixiris aromatici, q. s. ad fjvj (175.0 c.c). — M. 

Sig. Tablespoonful in water after meals. 



I40 SPINAL CORD EXCITANTS, 

VIBURNUM PRUNIFOLIUM, U. S. P. 

(Black Haw.) 

Officially viburnum prunifolium is the bark of a tall shrub 
of the same name, growing in the eastern and southern States 
of North America. Its chief constituents are viburnin (a bitter 
principle), valerianic acid, resin, and tannin. 

Preparation. Dose. 

Fluidextractum Viburni Prunifolii, U. S. P. . . \-2. fl. dr. (2.0-8.0 c.c). 

Therapeutics. — Large doses of the fluid extract are said 
to cause in warm-blooded animals drowsiness, a fall of blood- 
pressure, muscular relaxation, and a diminution of reflex irri- 
tability. It is employed chiefly as a uterine and ovarian seda- 
tive. It has been found useful in habitual abortion occurring 
in non-syphilitic patients. Combined with opium it is very 
efficacious in threatened abortion. In non-inflammatory dys- 
menorrhea it affords great relief when given in doses of 1 
dr. (4.0 c.c.) three times a day, beginning five or six days before 
menstruation. It is sometimes very successful in subduing 
the menstrual irregularities and nervous distress occurring 
about the time of the menopause. 

OLEUM SUCCINI. 

(Oil of Amber.) 

Oil of amber is a volatile oil obtained by the destructive dis- 
tillation of a fossil resin which is yielded by submerged fir 
trees washed ashore along the coast of Prussia. It is a thin, 
transparent, yellow liquid, having a balsamic odor and a warm, 
acrid taste. The dose is from 5-10 min. (0.3-0.6 c.c), in cap- 
sules or in an emulsion. 

Therapeutics. — Oil of amber, with camphor or turpen- 
tine, was at one time held in high repute as a stimulating 
liniment for the chest in whooping-cough and acute bronchitis. 
Internally it is sometimes efficacious in obstinate hiccough. 



SPINAL CORD EXCITANTS. 

Spinal cord excitants, or excitomotors, are drugs which 
increase the functional activity of the spinal cord. By stimu- 
lating the cell-bodies of the lower motor neurons they exag- 
gerate reflex activity, and if given in toxic dose, induce tetanic 
convulsions. The origin of the convulsions excited by a drug 
can be determined in animals by dividing the spinal cord 



NUX VOMICA. 141 

between the occiput and the atlas. Convulsions of cerebral 
origin cease after section, while those of spinal origin do not. 
The most important spinal cord excitants are : 

Strychnin. Cafifein. 

Brucin. Ammonium salts. 

Hydrastin. Phenol. 

With the exception of strychnin and brucin, however, these 
drugs do not sensibly excite the spinal cord unless given in 
toxic doses. 

The indications for using excitomotors as such cannot be 
stated very definitely. They often prove efficacious, however, 
when loss of power is dependent upon depression of the motor 
neurons, and not upon destructive lesions. When there is 
evidence of inflammation they are absolutely contraindicated. 

NUX VOMICA, U. S. P. 

Nux vomica is the seeds of the Strychnos Nux vomica, a. 
small tree growing in the East Indies. It contains two alka- 
loids, strychnin and brucin. Strychnin fully represents the 
action of the crude drug. It is official as Strychnina, which is 
very sparingly soluble in water, as Strychnines nitratis, which 
is soluble in 42 parts of water, and as Strychnines sulphatis, 
which is soluble in 3 1 parts of water. All these preparations 
appear as colorless crystals or crystalline powders, having an 
intensely bitter taste. Brucin resembles strychnin in its action, 
but is less powerful. The dose of strychnin or of either of its 
salts is from 6 1 - 2 1 o g r - (0.001-0.003 g m -)- 

Preparations. Dose. 

Extractum Nucis Vomicae, U. S. P \-\ gr. (0.008-0.03 g m -)- 

Fluidextractum Nucis Vomicae, U. S. P. . . . 1-5 min. (0.06-0.3 gm.). 

Tinctura Nucis Vomicae, U. S. P 5-20 min. (0.3-I.3 c.c). 

Pulvis Nucis Vomicae, 1-5 gr. (0.06-0.3 g 111 -)- 

Strychnin enters into the glycerite of the phosphates of 
iron, quinin, and strychnin, the syrup of the phosphates of iron, 
quinin, and strychnin, the compound syrup of hypophosphites, 
and compound laxative pills. 

Physiologic Action. — Circulatory System. — In full me- 
dicinal doses strychnin raises the blood-pressure and slightly 
lessens the frequency of the pulse. The first of these effects is 
chiefly the result of vasoconstriction induced by stimulation of 
the vasomotor center in the medulla, the heart being stimulated 
but feebly, if at all. The decreased frequency of the pulse is 
due to stimulation of the cardiac inhibitory center. 



142 SPINAL CORD EXCITANTS. 

Toxic doses tend to lower the blood-pressure by depressing 
the vasomotor center ; but during the convulsive seizures in- 
duced by the drug an enormous increase in the pressure may 
be observed as a result of the violent muscular contractions. 

Nervous System. — Strychnin is a powerful stimulant of the 
spinal cord and medulla. Upon the cerebrum it has compara- 
tively little influence. Toxic doses increase reflex irritability of 
the spinal cord to such an extent that the slightest stimulus from 
the periphery induces violent tetanic convulsions. There is rea- 
son to believe that this effect is not the result of direct stimulation 
of the motor cells in the anterior horns, but of decreased resist- 
ance on the sensory side of the cord, in consequence of which 
slight impulses from the periphery, instead of reaching and in- 
fluencing but a limited number of motor cells, as is normally 
the case, are permitted to spread out and excite the motor cells 
of the entire cord. Thus, in frogs, convulsions do not follow 
strychnin injections after division of the sensory roots or par- 
alysis of the sensory nerve-endings by cocain. 

After a time, especially in the lower animals, the stimulant 
effects of strychnin are replaced by those of paralysis, the cen- 
tral nervous system and motor nerve-endings both sharing in 
the depression. 

Special Senses. — The special sense-organs also appear to 
be sensitive to strychnin, for after its use vision, hearing, and 
smell become more acute. 

Muscle. — By increasing the sensitiveness of the spinal cord 
to all centripetal sensory irritation, stiychnin improves the 
tonus of both plain and striped muscles throughout the body. 

Respiratory System. — The respiratory movements are 
quickened and strengthened by strychnin, owing to its stimu- 
lant action on the medullary center. 

Alimentary Canal. — Taken by the mouth, strychnin and the 
preparations of nux vomica, like other very bitter substances, 
whet the appetite, increase the secretions, and stimulate the 
peristaltic movements of both stomach and bowels. 

Metabolism. — By increasing muscular activity, strychnin 
augments considerably the consumption of oxygen and the 
output of carbonic acid. 

Elimination. — Strychnin is eliminated chiefly by the kid- 
neys. Its excretion is very slow, and, therefore, the possibility 
of cumulative effects arising from the prolonged and continuous 
use of the drug should be borne in mind. 

Toxicology. — The first evidences of the toxic effects of 
strychnin are restlessness, anxiety, twitching and starting of 
the muscles, and stiffness of the neck. If the dose has been 



NVX VOMICA. 1 43 

sufficiently large, spinal convulsions speedily develop, throwing 
the patient's body into orthotonos or opisthotonos. The con- 
vulsions are, for the most part, intermittent, and are repeated 
under the slightest external irritation. The pupils are dilated, 
the vision is hyperacute, the mind is unaffected, and the 
stomach is usually retentive. In fatal cases the convulsions 
become more rapid and severe, and finally death results from 
asphyxia due to spasmodic fixation of the respirator}* muscles 
or from exhaustion. In the lower animals very large quanti- 
ties of the drug may kill by paralyzing the central nervous 
system or the motor nerve-endings. The fatal dose of strych- 
nin for man is from J to ij grains (0.032-0.1 gm.). 

The history of the case, the absence of a wound, the abrupt 
onset, the intermittent character of the convulsions, and the 
late involvement of the muscles of the jaw (trismus i will serve 
to distinguish strychnin-poisoning from tetanus. 

The history of the case, the emotional excitement, the closed 
eyes, and the persistent opisthotonos will serve to distinguish 
hysteria from strychnin-poisoning. 

Treatment. — Since the slightest stimulus will provoke con- 
vulsions, the patient should be disturbed as little as possible. 
If convulsions have already begun, no attempt should be 
made to use a stomach-pump until the reflex excitability- has 
been subdued by inhalations of chloroform or amy] nitrite. 
Tannic acid in solution may be administered as a chemical 
antidote. The best physiologic antidotes are potassium bro- 
mid (.5J-ij — 4.0-8.0 gm.) and chloral (20 gr. — 1.3 gm.): when 
the patient is unable to swallow the chloral, I dr. (4.0 gm.) 
may be given in an enema. Osterwald observed very bene- 
ficial effects from oxygen inhalations in strychnin-poisoning in 
animals. 

Therapeutics. — Nux vomica or strychnin is used chiefly 
as a circulatory* stimulant, a respirator}* stimulant, an excito- 
motor, and a stomachic. 

As a Circulatory Stimulant. — In simple dilatation of the 
heart, with or without valvular disease, strychnin often renders 
good service when combined with digitalis, but used alone it is 
distinctly inferior to the latter drug. In pneumonia and other 
infective processes it is an excellent adjuvant to alcohol and 
digitalis. In the weak heart of the old it is generally a better 
remedy than digitalis. It is also useful in surgical she:': 

As a Respiratory Stimulant. — Being both a respiratory 
and a circulator}* stimulant, strychnin is indicated in diseases 
of the lungs associated with enfeeblement of the respiration 
and pulse, such as pneumonia, emphysema, and some cases of 



144 SPINAL CORD EXCITANTS. 

chronic bronchitis and phthisis. In emphysema no single drug 
is so useful. Employed hypodermically in cases of acute pul- 
monary edema it is scarcely less efficient than atropin. 

In poisoning by drugs which depress the heart or respiratory 
center strychnin is of value. In poisoning by opium, chloral, 
aconite, ether, or chloroform it should be given hypoderm- 
ically in full doses. 

As an Excitomotor. — When paralysis is the result of com- 
plete destruction of nerve-cells or fibers, strychnin, like all 
other drugs, will be ineffective ; but when the loss of power is 
the result simply of depression or exhaustion of the nervous 
apparatus, it may prove useful. It is commonly prescribed in 
the hemiplegia following apoplexy, but it is valueless in this 
condition except, perhaps, as a general tonic. On the other 
hand, in the various forms of peripheral neuritis, such as 
plumbic, alcoholic, diphtheritic, and that due to pressure, it is 
often of considerable service. It should not be used, how- 
ever, until all acute symptoms of the affection have subsided. 

In neurasthe7tia minute doses of strychnin with arsenic are 
sometimes efficacious, but more often the drug is useless or 
actually harmful. In amaurosis from tobacco, alcohol, or lead 
it is invaluable. 

It is thought that intramuscular injections of strychnin aid 
in restoring power to the affected muscles in acute poliomyelitis. 
This treatment, however, should not be instituted until three 
or four weeks after the incidence of the disease. Nux vomica 
often affords relief in incontinence of urine from atony of the 
bladder — a condition sometimes met with in old people. It is 
likewise an excellent remedy in constipation dependent upon 
atony of the intestinal walls. 

As a Stomachic. — Nux vomica is often very useful in 
chronic dyspepsia when there are no manifestations of severe 
inflammatory trouble. In these cases the chief symptoms are 
a coated, flabby tongue, anorexia, fulness and distress for 
some time after eating, deficient secretion of hydrochloric acid, 
flatulence, and constipation. In such types of indigestion the 
tincture of nux vomica (5 or 10 drops before meals), with or 
without hydrochloric acid, often acts most happily. In larger 
doses it is also of service in dilatation of the stomach due to 
atony. It is a trustworthy remedy in those cases of marked 
flatulence, common in elderly people, dependent upon a lack 
of tone in the walls of the stomach and bowel. 

Strychnin is contraindicated in gastric affections when there 
is hypersecretion of hydrochloric acid, and when there are 
evidences of well-marked inflammation. 



SPINAL CORD DEPRESSANTS. 1 45 

Other Uses. — In hyperemesis not dependent upon organic 
disease of the stomach, the tincture of nux vomica (1-2 drops) 
alone, or with wine of ipecac (J— 1 drop), every hour or two, 
will often afford relief. Good results are sometimes obtained 
with strychnin as a prophylactic remedy in uterine inertia. It 
has been recommended by Murrell and Brunton to check the 
night-sweats of phthisis. It is useful in sexual impotence due 
to lowered nervous tone. Dana and others speak very favor- 
ably of strychnin in heroic doses in tic douloureux occurring in 
anemic and exhausted patients, and when the duration of the 
disease has not been more than one or two years. The drug 
is given hypodermically once a day, and the dose is gradually 
increased from -^ to \ of a grain (0.002 to 0.013 gm.), ten to 
twenty days being required to reach this maximum. A number 
of observers (Posner, Feilchenfeld, Ketly, Spaether) speak 
favorably of the action of strychnin in diabetes insipidus. 

Administration. — Strychnin sulphate and extract of nux 
vomica are suitable preparations for use in pills. When a 
liquid preparation is desired, as in atony or dilatation of the 
stomach, the tincture will be found reliable. The nitrate of 
strychnin is sometimes preferred to the sulphate for hypodermic 
use, but it has no special advantage over the latter. Nervous 
excitement, restlessness, and twitching of the muscles are indi- 
cations that the limit of physiologic action has been reached. 

Incompatibles. — Strychnin is incompatible with tannic 
acid, alkalies, chlorids, iodids, and bromids. 



SPINAL CORD DEPRESSANTS. 

Under this head are considered drugs that lessen reflex 
action by depressing the neurons of the spinal cord. They 
may act solely on the motor neurons, impairing their ability to 
discharge power, or they may act also on the sensory neurons 
and thus protect the motor neurons from the influence of pe- 
ripheral irritation. The following are most important members 
of this group: 

Physostigma. Hydrated chloral. 

Gelsemium. Ether. 

Bromids. Chloroform. 

Spinal cord depressants are useful in combating symptoms 
resulting from irritation of the neurons of the lower motor 
segment. Thus, they are of value in controlling the paroxysms 
10 



I46 SPINAL CORD DEPRESSANTS. 

of laryngismus stridulus, the spasms of tetany, and the tremors 
of paralysis agitans. They are also of service in allaying the 
hyperexcitability of the lower motor neurons caused by cer- 
tain poisons, as strychnin and that of tetanus. Finally, spinal 
cord depressants are not without value in the treatment of 
convulsive seizures which have a cerebral origin ; for by de- 
pressing the lower motor neurons they impair their power 
of transmitting excessive discharges from the brain to the 
muscles, and by depressing the lower sensory neurons they 
afford the brain more or less protection from the effects of 
external stimuli. 

PHYSOSTIGMA, U. S. P. 

(Calabar Bean.) 

Physostigma is the seed of Physostigma venenosum, a 

perennial climber, growing in West Africa. It contains two 
alkaloids, physostigmin or cserin, and calabann ; the latter is 
less important than the former, and resembles strychnin in 
its action. 

Preparations. Dose. 

Tinctura Physostigmatis, U. S. P. ... 5-30 min. (0.3-1.8 c.c). 

Extraction Physostigmatis, U. S. P . . . \-\ gr. (0.008-0.02 gm.). 

Physostigmin, or eserin, fairly represents the active properties 
of the bean. It occurs in yellowish-white crystals, deliques- 
cent, odorless, bitter, sparingly soluble in water, but readily so 
in alcohol and dilute acids, and turning pink on exposure. 
The dose is from 1 \ 3^ gr. (0.0005-0.002 gm.). Two salts 
are official : 

Physostigminse sulphas. 

Physostigminae salicylas. 

The sulphate is very soluble in water, and the salicylate is 
soluble in 72.5 parts of water. The dose of either salt is from 
TT>o-3T) S r - (0.0006-0.002 gm.). 

Physiologic Action. — Circulatory System. — Small ther- 
apeutic doses of physostigmin do not affect the circulation. 
Large doses decrease the pulse-rate and strengthen the beat, 
probably by acting on the heart-muscle directly. They also 
raise the blood-pressure, partly by powerfully contracting the 
intestines and thus driving the blood out of the splanchnic 
area, and partly by stimulating the muscular coat of the 
arterioles. Toxic doses lower the blood-pressure by depressing 
the vasomotor center. 

Central Nervous System. — In large doses physostigmin 
lessens reflex activity and induces muscular weakness by 



PHYSOSTIGMA. 1 47 

depressing the motor neurons of the spinal cord. It also de- 
presses the medullary centers, but it is apparently without 
influence on the cerebrum, for in poisoning consciousness is 
preserved until the end. 

Respiratory System. — Therapeutic doses do not affect the res- 
piration, but toxic doses kill by paralyzing the respiratory center. 

Muscles. — Physostigma increases the irritability of both 
striped and unstriped muscle, and in toxic doses causes fibril- 
lary tremors and tetanoid contractions. The latter appear to 
be due to stimulation of the peripheral nerve-endings, as they 
occur after section of the nerve-trunks, but disappear after 
injections of curare. 

Secretions. — Large doses of physostigmin increase the flow 
of saliva, sweat, mucus, and pancreatic juice by stimulating 
the nerve-endings in the secretory glands. This action is offset 
by large doses of atropin. 

Alimentary Canal. — Physostigmin powerfully increases the 
peristaltic movements of the stomach and bowel by stimu- 
lating the nerve-endings in the muscular coat of these organs, 
and probably also the muscular protoplasm itself. 

Bye. — Local applications of physostigmin cause marked 
contraction of the pupil by stimulating the peripheral endings 
of the oculomotor nerve, and probably also the iris muscle 
itself. They also induce spasm of accommodation by acting 
similarly on the ciliary muscle, and decrease intraocular ten- 
sion, partly by narrowing the pupil and partly by constricting 
the ocular vessels. 

Toxicology. — Physostigmin-poisoning is characterized by 
vertigo, great muscular relaxation, tremors and twitchings 
of the muscles, abolition of reflex action, contraction of the 
pupils, slowing of the pulse, salivation, and sometimes colicky 
pains with nausea and vomiting. 

Treatment of Poisoning". — This consists in evacuating the 
stomach by an emetic, in administering atropin as a physio- 
logic, and tannic acid as a chemical, antidote, and in combating 
respiratory and cardiac failure with such stimulants as am- 
monia, strychnin, and alcohol. 

Therapeutics. — Physostigma has a very limited range of 
usefulness ; it is chiefly employed to depress the spinal cord, 
to contract the pupils, to lessen intra-ocular tension, and to 
stimulate involuntary muscles, especially those of the stomach 
and intestine. 

It has been used to depress the spinal cord in tetanus, 
strychnin-poisoning, and chorea, but in these affections we 
have far more reliable remedies. 



I48 SPINAL CORD DEPRESSANTS. 

The extract sometimes makes a useful addition to cathartic 
pills intended to relieve constipation dependent upon atony of 
the intestinal walls. In full doses, preferably hypodermically, 
it is sometimes serviceable in the excessive tympanites of typhoid 
fever, and in postoperative intestinal paresis. Ringer has rec- 
ommended it in chronic bronchitis with dyspnea, due to weak- 
ness of the bronchial muscles. It has found favor with some 
practitioners in the treatment of atonic dilatation of the stomach. 

Eye-affections. — Physostigmin sulphate is used to coun- 
teract mydriasis produced by atropin, to lessen intra-ocular 
tension in the early stages of glaucoma, and sometimes alter- 
nately with atropin to break up adhesions in iritis. In per- 
ipheral ulceration of the cornea, in the absence of iritis, it often 
acts better than atropin. 

Untoward Effects. — Strong solutions instilled into the eye 
sometimes cause pain in the eye and head, spasm of the 
ocular muscles, vertigo, and faintness. 

Administration. — Physostigma may be given internally 
in the form of the extract, the tincture, or the alkaloid. For 
hypodermic use physostigmin sulphate is preferable on account 
of its ready solubility in water. For the same reason the 
sulphate should be employed in affections of the eye. For 
continued use it is generally prescribed in solutions containing 
from -|— I gr. (0.008-0.065 gm.) to the ounce (30.0 c.c), but 
when a powerful and prompt effect upon the eye is desired 
much stronger solutions (2-3 gr. — 0.13-0.2 gm.) to the ounce 
(30.0 c.c.) may be employed. On standing solutions of eserin 
turn red and lose some of their effectiveness. 

GELSEMIUM, U. S. P. 

(Yellow Jasmine.) 

Gelsemium is the rhizome and root of Gelsemium semper- 
virens, a climber indigenous to the southern United States. It 
contains gelseminin and gelsemin. Gelseminin, which repre- 
sents to a considerable extent the active properties of the crude 
drug, occurs in the form of white crystals, with a bitterish 
taste, sparingly soluble in water, and readily soluble in alcohol, 
ether, and dilute acids. The dose of gelseminin or its salts is 
from y^o-sV gr. (0.0005-0.002 gm.). 

Preparations. Dose. 

Tinctura Gelsemii, U. S. P 5-20 rain. (0.3-1.2 c.c). 

Fluidextractum Gelsemii, U. S. P 1-5 min. (0.05-0.3 c.c). 



OTHER SPINAL CORD DEPRESSANTS. 1 49 

Physiologic Action. — Circulatory System. — Small doses 
do not affect the circulation, but very large doses quicken the 
pulse by depressing the ganglia on the inhibitory nerve. 

Nervous System. — Gelsemium depresses the spinal cord, 
especially its motor neurons, and also, though less powerfully, 
the terminations of the motor nerves. 

Respiratory System. — Toxic doses kill by paralyzing the 
respiratory center. 

Bye. — Locally applied, gelseminin dilates the pupil and 
paralyzes accommodation, these effects being produced, as 
with atropin, by depression of the endings of the third nerve. 

Toxicology. — Gelsemium-poisoning is characterized by 
vertigo, frontal headache, disordered vision, dilatation of the 
pupils, ptosis, falling of the jaw, failure of articulation, extreme 
muscular weakness, slow respiration, a weak, thready pulse, 
and, finally, collapse. Consciousness is usually retained until 
near the close of life. Convulsions have been observed in 
animals, but not in man. 

Treatment. — Restorative measures consist in evacuating 
the stomach, administering tannic acid, maintaining the body- 
temperature, and combating collapse with such stimulants as 
strychnin, whisky, and ammonia. 

Therapeutics. — Gelsemium has been employed as an anti- 
spasmodic in laryngismus stridulus, whooping-cough, asthma, 
and chorea, but in these affections there are far more efficient 
remedies. At one time gelseminin was recommended as a 
mydriatic, but homatropin and atropin are superior, being 
more prompt and less dangerous. The drug is sometimes 
distinctly useful in spasmodic affections of the muscles, like 
torticollis, and in obstinate neuralgia, especially of the trifacial 
nerve. In the latter, a combination of butyl-chloral hydrate 
(5 gr. — 0.3 gm.) and gelseminin (y^- gr. — 0.0006 gm.), as recom- 
mended by Murrell, is particularly efficacious. Ringer has 
found it useful in some cases of Meniere's disease. On account 
of the variability of the preparations, they should be given 
in small doses, gradually increased until such symptoms as 
vertigo or dimness of vision appear. In persistent torticollis 
gelseminin may be injected directly into the muscle. 

OTHER SPINAL CORD DEPRESSANTS. 

Hydrated Chloral.— The depressant action of hydrated 
chloral on the motor tracts of the spinal cord is secondary in 
importance only to that on the cerebrum. In tetanus and 
strychnin-poisoning it renders valuable service in allaying the 
irritability of the spinal motor neurons. 



150 MOTOR NERVE DEPRESSANTS. 

Chloroform and Ether. — These drugs depress both the 
sensory and motor neurons of the spinal cord, but the former 
more powerfully than the latter. They are useful in checking 
convulsions which endanger life, whether the motor discharges 
emanate from the brain or from the spinal cord. As spinal 
cord depressants they are of value in cerebral convulsions by 
lessening the power of the sensory columns to transmit to the 
brain stimuli from without, and also by lessening the power 
of the motor columns to convey discharges from the brain to 
the muscles. 

Bromids. — The bromids depress the entire central nervous 
system, first the cerebrum, then the spinal cord, and lastly the 
medulla. As depressants of the spinal cord they are useful in 
subduing the convulsive seizures of strychnin-poisoning and 
tetanus. 



MOTOR NERVE DEPRESSANTS. 

The most important depressants of the peripheral motor 
nerves are : 

Curare. Conium. 

Belladonna. Gelsemium. 

Lobelia. Spartein. 
Pelletierin. 

Of this group, however, only belladonna, conium, and, per- 
haps, lobelia are employed for their effect on the nerve-endings. 
Curare is a resinous extract, obtained from various species of 
strychnos, growing in South America. Taken by the mouth, 
it has little or no effect, but introduced into the body through 
an open wound or by subcutaneous or intravenous injection, it 
is a powerful paralyzant of the nerve-endings in all striated 
muscle except that of the heart. It has been used to some ex- 
tent in hydrophobia and tetanus, but without much success. The 
dose is from 2V~i g ra i n (0.0032-0.032 gm.), subcutaneously. 
The action of gelsemium on the motor nerves is subordinate to 
its action on the central nervous system. Pelletierin, an alkaloid 
of pomegranate, affects the motor nerve-endings only in toxic 
doses. The action and uses of belladonna have been fully con- 
sidered on page 75. 

Motor nerve depressants are useful in local spasmodic 
affections like whooping-cough, torticollis, and asthma. 



COXIUM—L OBELIA. 1 5 I 

CONIUM, U. S. P. 

^Hemlock.) 

Conium is the fruit of the Conium maadatiim, gathered 
while yet green. It contains a volatile oil and a yellowish, 
oily, liquid alkaloid, conii n, which represents the active prop- 
erties of the drug. Coniin forms with acids crystallizable salts 
which are soluble in water. The dose of the alkaloid or its 
salts is from ^ \ gr. (0.003-0.01 gm.). 

Preparations. Dose. 

Fluidextractum Conii, U. S. P 2-5 min. (0.1-0.3 c.c.V 

Extractum Conii h-2 gr. (0.03-0. 13 gm.). 

Tin cmra Conii |-i fl. dr. (2.0-4.0 c.c). 

Physiologic Action. — Toxic doses of conium produce a 
staggering gait, muscular relaxation, paralysis, tremors, ver- 
tigo, ptosis and dilatation of the pupils (from paresis of the 
oculomotor nerve), coldness of the surface, and, finally, death 
from asphyxia. Salivation, nausea, vomiting, and diarrhea 
may also be observed. Consciousness and sensibility are pre- 
served until near the end. 

The dominant action of the drug is on the peripheral motor 
nerves, which it paralyzes. Its action on the spinal cord con- 
sists of transient stimulation, followed by profound depression. 
On the brain it exerts no special influence. 

Whether the failure of respiration observed in poisoning is 
the result of paralysis of the respirator}' center or of the nerve- 
endings in the diaphragm has not definitely been determined. 
Except in very large doses, conium has but little depressant 
effect on the heart. 

Therapeutics. — Conium has been used as an antispas- 
modic in chorea, paralysis agitans, astJima, and zuhooping- 
cough, but in these affections it is of less value than other 
remedies. In the form of vapor it is sometimes useful in 
allaying the cough of bronchitis. Spitzka and others strongly 
recommend it in the mental and physical excitement of acute 
mania. On account of the uncertain strength of the prepara- 
tions, it is necessary to give the drug in small doses rapidly 
increased until some effect is produced. 

LOBELIA, U. S. P. 

Lobelia is the leaves and tops of Lobelia i?iflata, a weed 
growing in the wild places of Canada and the United States. 
It contains lobelic acid and a yellow liquid alkaloid, lobelin. 
The latter forms, with acids, crvstalline salts, which are soluble 



152 MOTOR NERVE DEPRESSANTS. 

in water. The dose of the sulphate of lobelin is from -|— I gr. 
(0.01-0.06 gm.). 

Preparations. Dose. 

f As an expectorant, IO-30 min. 

Tinctura Lobelia, U. S. P 1 As an em°tic, C i-2 fl. dr. (2.0-4.0 

I c.c). 

f As an expectorant, 2-5 min. (o. I- 
0."2 c.c. ). 
Fluidextractum Lobelise, U. S. P. . . . j As an emetic, 20-30 min. (1.2- 

l 2.0 c.c). 

Physiologic Action. — Lobelia has practically the same 
action as conium, except that it is more prone than the latter 
to produce nausea and vomiting. It paralyzes the peripheral 
terminations of the motor nerves, and appears to be especially 
depressant to the endings of the vagus distributed to the 
bronchial muscles. The ingestion of a large dose of the drug 
(a teaspoonful of the tincture) is followed by nausea, vomiting, 
and faintness. Toxic doses cause severe burning pain in the 
esophagus and stomach, persistent vomiting, cold sweats, 
weakness of the pulse, extreme prostration, and, finally, death 
from paralysis of the respiratory center. 

The treatment of lobelia-poisoning consists in the administra- 
tion of tannic acid and of diffusible stimulants, and in the use 
of artificial heat to maintain the bodily temperature. 

Therapeutics. — Lobelia was formerly used as an emetic, 
but as such it has been almost entirely displaced by less de- 
pressing drugs. It is, however, an exceedingly useful anti- 
spasmodic in asthma and in bronchitis associated with spas- 
modic dyspnea. To secure the best results, it is necessary 
to give the drug in increasing doses until slight nausea is 
produced. 

SPARTEINE SULPHAS, U. S. P. 

Spartein is a liquid alkaloid obtained from the tops of Cytisns 
Scoparius, or common broom. It is official as Sparteines sul- 
phas, a white crystalline or granular powder of a somewhat 
bitter taste, and freely soluble in water and alcohol. The dose 
of spartein sulphate is J grain (0.015 gm.), cautiously increased 
to 1 grain (0.06 gm.). 

Physiologic Action. — Spartein closely resembles coniin 
in its action, though it has less effect on the central nervous 
system, and is less poisonous than the latter. As is the case 
with coniin, large doses depress the motor nerve-endings and 
the sympathetic nerve cells. The drug also depresses the 



SENSORY NERVE DEPRESSANTS. 1 53 

heart directly, and so lessens both force and frequency of the 
cardiac contractions. Under its influence the blood-pressure 
usually falls, though at first it may slightly rise from constric- 
tion of the peripheral vessels. Spartein has been employed 
rather extensively as a substitute for digitalis in cardiac insuffi- 
ciency, but the actions of the two drugs are entirely dissimilar. 



SENSORY NERVE DEPRESSANTS. 

When applied locally a drug may lessen or destroy sensi- 
bility through a specific action on the peripheral nerves, or, as 
is the case with ether and ethyl chlorid, through the intense 
cold produced by its evaporation. A few drugs when taken 
internally, if the dose be sufficiently large, are capable of pro- 
ducing numbness of the skin and mucous membranes through 
a peripheral action. This is true of aconite and the bromids. 

Sensory nerve depressants are employed locally to relieve 
pain and to allay itching. 

The following agents act as local anesthetics : 

Cocain. Menthol. 

Tropacocain. Camphorated chloral. 

Phenol. 
Iodoform. 
Esters of benzoic Aconite, 
acid. Veratrin. 



Eucain. 

Orthoform. 

Anesthesin. 

Stovain. 

Novocain. 



Hydrocyanic acid. 



Holocain. Ethyl chlorid. 

Chloretone. Ether. 

Many of the aromatic oils, like oil of cloves and oil of 
peppermint, also possess anodyne properties. 

Cocain (see p. 83). — The application of a cocain solution 
of moderate strength (6 per cent.) to a mucous membrane is 
followed in a few moments by pallor and anesthesia. The 
pallor is due to constriction of the blood-vessels, and is subse- 
quently replaced by congestion ; the anesthesia is due to the 
direct action of the drug upon the sensory nerves. Applied 
to cutaneous surfaces it is without effect, since absorption 
through the skin is very slight. In the eye it causes, in addi- 
tion to anesthesia, mydriasis and a slight impairment of 
accommodation. 

The uses of cocain as a local anesthetic are various. In 
operations on the eye, nose, throat, urethra, and rectum, its solu- 
tions are indispensable in preventing or in lessening pain. 



I 54 SENSOR Y NER VE DEPRESSANTS. 

When injected under the skin it is also of established value 
in many minor operations involvi?ig the cutaneous structures, 
such as circumcision, opening small abscesses, amputating 
fingers, and excising small growths. 

In inflammations and ulcerations of the nose, pharynx, and 
larynx it may be employed alone or in combination with anti- 
septic sprays and powders. In acute coryza and hay-fever it 
gives much relief by lessening the sensibility and the tumes- 
cence of the tissues. In tuberculous laryngitis it serves a useful 
purpose in lessening the intense pain and dysphagia. It is 
also efficacious in diminishing the pain caused by the applica- 
tion of caustics. 

For anesthetizing mucous membranes solutions are em- 
ployed varying in strength from 2-20 per cent. On the nose 
and throat from 4-6 per cent, solutions are usually sufficient. 
In the larynx somewhat stronger solutions are required 
Solutions stronger than 4 per cent, should not be used in the 
eye on account of the danger of inducing degenerative changes 
in the corneal epithelium. When the drug is employed sub- 
cutaneously after the method of Schleich, it is not safe to allow 
more than 1 grain to remain in the tissues. 

I£ttcain. — Eucain is a synthetic compound allied chemi- 
cally to cocain. Two forms are upon the market, which are 
known respectively as Alpha-eucain or eucain hydrochlorid 
"a" and Beta-eucain or eucain hydrochlorid " fi." The 
former, on account of its irritant properties, has been almost 
completely supplanted by the latter. Beta-eucain occurs as a 
white, neutral, crystalline powder, soluble in about 30 parts 
of cold water, making a 3 per cent, solution. It is somewhat 
less toxic than cocain, and, moreover, its solutions are more 
stable, and can be sterilized by boiling without losing in effi- 
cacy. A disadvantage of eucain is that it has no constricting 
influence on the blood-vessels, in consequence of which it 
causes hyperemia rather than ischemia. When injected sub- 
cutaneously it is somewhat more liable than cocain to induce 
sloughing. 

For general surgical purposes a 2 per cent, solution (9 gr.- 
I oz. — 0.6 gm-30.0 c.c.) is generally employed. 

Holocain. — Holocain is a synthetic compound related 
chemically to phenacetin. The hydrochlorid, in which form 
it is always employed, occurs in colorless crystals, having a 
bitter taste and slightly soluble in cold water. 

It is very sensitive to alkalies — even the small amount of 
alkali dissolved out of the glass on boiling a solution of the 
drug in a test-tube is sufficient to decompose it. 



TR OP A COCA IN HYDROCHL OR A TE—ORTHOFORM. I 5 5 

Experimentally holocain has been found to be more actively 
poisonous than cocain, and therefore it is not suitable for sub- 
cutaneous use. It has qualities, however, which make it a 
very valuable anesthetic in ophthalmic surgery. The instilla- 
tion into the eye of a few drops of a 1 per cent, solution of 
holocain causes slight burning, and is followed in from twenty 
to thirty seconds by complete anesthesia, lasting for from ten 
to fifteen minutes. It is without effect upon the pupil, the 
ciliary muscle, the intra-ocular tension, or the corneal epi- 
thelium. It is more rapid in its action than cocain, and it has, 
moreover, some bactericidal power. As it has no constricting 
effect upon the blood-vessels, it lacks the power of cocain to 
control hemorrhage. 

Since it acts so quickly and does not cause mydriasis, it is 
especially valuable in minor operations on the eye, such as the 
removal of foreign bodies. Norris has found it very efficacious 
in sluggish corneal ulcers, and de Schweinitz and others have 
spoken favorably of it in keratitis. 

A 1 per cent, solution is usually employed. When the eye 
is inflamed, the effectiveness of both holocain and cocain is 
distinctly enhanced by the previous application of a solution 
(1 : 10,000) of adrenalin. 

Tropacocain Hydrochloric!. — Tropacocain is an alka- 
loid obtained from the small Java coca leaves. It forms white 
needles which are readily soluble in water. It resembles 
cocain in its action, but it is much less toxic, and when applied 
to mucous membranes it does not cause ischemia. 

It anesthetizes the eye without affecting the pupil or accom- 
modation, but it has no advantages over holocain. On account 
of its lesser toxicity it may replace cocain in solutions intended 
for infiltration anesthesia, especially when it is necessary to 
employ large doses of the anesthetic. Block recommends the 
following solution : 

Tropacocain hydrochloric!, 3 gr. (0.2 gm.) ; 

Sodium chlorid, 3 gr. (0.2 gm. ) ; 

Sterilized distilled water, 3 fl. oz. (100.0 c.c). 

It has also been used successfully in the production of medul- 
lary anesthesia, from J— i gr. (0.26-0.05 gm.) being injected 
for this purpose into the subarachnoid space. 

Orthofortn. — This synthetic compound is the methyl-ester 
of meta-amido-para-oxybenzoic acid. It occurs as a white, 
voluminous powder, without odor or taste, and sparingly 
soluble in water. Orthoform hydrochlorid is freely soluble 
in water, but it is too irritating for general use. Orthoform 



156 SENSORY NERVE DEPRESSANTS. 

has pronounced analgesic, antiseptic, and desiccant properties, 
and for this reason it has been recommended as a dressing for 
painful wounds and ulcers. 

When applied pure or in the form of an ointment (10-20 
per cent.) to exposed sensory nerve-endings it causes a slight 
burning sensation, which is soon followed by complete anal- 
gesia lasting from ten to twenty hours. The prolonged action 
of the drug is due in large part to the slowness with which it 
is absorbed. On account of its acid reaction it is too irritating 
to be applied to sensitive mucous membranes like the eye or to 
be injected hypodermically. Unfortunately it is not altogether 
free from toxic properties, and its effects should be carefully 
watched. Brocq, Asam, Yonge, and others have seen exten- 
sive erythema, urticaria, eczema, and even gangrene follow its 
use. A study of the published records indicates that these 
accidents are more likely to occur from the use of the drug in 
an ointment than when it is applied directly in the form of a 
powder. 

Orthoform has been used successfully as a local remedy in 
painful wounds, in burns, especially of the third degree, in 
cancerous and tuberculous ulcerations, and in fissures and ex- 
coriations of the mucocutaneous junctions. It will be found 
very efficacious in relieving the pains of tuberculous laryngitis 
and of fissured nipples. In the former the powdered drug may 
be used ; in the latter, a saturated alcoholic solution, or an 
ethereal solution like the following, recommended by Bardet : 

ij Orthoform gr. lxxx (5.0 gm.); 

^Etheris, q. s. ad solv. ; 

Olei amygdalae expressi, f ^j (30.0 c.c). 

Added to arsenical pastes (orthoform, 1 part ; acacia, 1 part ; 
arsenous acid, 2 parts) it materially lessens the painfulness of 
their caustic action. Its internal use in doses of from 5-10 gr. 
(0.3-0.65 gm.) has been recommended in gastric ulcer and 
cancer, but Epstein has observed vomiting and collapse after 
its administration by the mouth. 

Orthoform is incompatible with silver nitrate, antipyrin, and 
bismuth subnitrate. 

Anesthesin. — This is the ethyl ester of paramidobenzoic 
acid. It is a white, inodorous powder, tasteless, but producing 
a sense of numbness when applied to the tongue. It is almost 
insoluble in water, soluble to the extent of 2 or 3 per cent, in 
oils, and readily soluble in alcohol. As a local anesthetic, anes- 
thesin has an action very similar to that of orthoform, but less 
irritant and less toxic. Locally, it is employed by insufflation 



STO VAIN— NO VOCAIN—CHL ORE TONE— MENTHOL. I 5 J 

in pharyngeal and laryngeal affections, as a dusting-powder 
or ointment in burns and painful ulceratio?zs of the skin, arid in 
the form of suppositories in hemorrhoids. Internally, it has 
been used with some success in relieving pain and vomiting 
the result of gastric ulcer or cancer. The dose is from 5 to 
IO grains (0.3-0.65 gm.), preferably in cachets. 

Stovain. — This synthetic compound — the hydrochlorid of 
an ester of benzoic acid — appears as small white lustrous crys- 
tals, very freely soluble in water. It is about equal to cocain 
in anesthetic power, but less toxic, and, moreover, has a vaso- 
dilating instead of a vasoconstricting effect. It has been rec- 
ommended particularly for local injections in minor surgical 
operations (0.5 to 1 per cent, to the extent of 2 grains — 0.13 
gm.) and for lumbar anesthesia (10 per cent, solution to the 
extent of \ to \\ grains — 0.03-0.07 gm.). In a few instances 
gangrene has been observed after subcutaneous injections. It 
may be applied to the conjunctiva in 4 per cent, solution, and 
to other mucous membranes and ulcerated surfaces in from 5 
to 10 per cent, solution. In prescribing stovain it should be 
borne in mind that it is incompatible with alkalis and mercuric 
salts. 

Novocain is a benzoic acid ester occurring as a crystalline 
salt, soluble in an equal weight of water. It is a powerful local 
anesthetic, more transient in its effect than cocain, but much less 
toxic and irritant. It may be applied in a 1 to 10 per cent, 
solution to the eye and in a 5 to 20 per cent, solution to the 
nose and larynx, with the addition of a little adrenalin solution 
to prolong the anesthesia. For infiltration anesthesia, a solu- 
tion of 1 to 2 per cent., also with adrenalin, may be used to 
the extent of 3 or 4 grains (0.2-0.25 gm.) without fear of 
toxic effects. It is incompatible with alkalis and alkaline 
carbonates. 

Chloretone (see p. 106). — This is a compound formed by 
the addition of potassium hydrate to equal weights of chloro- 
form and acetone. It appears as a white, crystalline powder, 
with a camphoraceous odor and taste. In addition to its use- 
fulness as a hypnotic it has a definite value as an antiseptic 
and a local anesthethic. It has been used with considerable 
success as a dusting-powder in painful wounds. It has also 
been employed in the form of a saturated solution for pro- 
ducing infiltration anesthesia, but the results have not been 
uniformly favorable. 

Menthol (peppermint camphor). — Menthol is a stearopten 
obtained from the essential oil of peppermint. It occurs as 
colorless prismatic or acicular crystals, having the odor of 



1 5 8 SENSOR Y NER VE DEPRESSANTS. 

mint and a camphoraceous taste. It is sparingly soluble in 
water, but freely so in alcohol, ether, and chloroform. The 
dose is from 1-3 gr. (0.06-0.2 gm.), in pills, capsules, or in 
alcoholic solution. 

Menthol is employed as a local anesthetic and an antiseptic. 
It makes a useful application in frontal headache and in neu- 
ralgia of the superficial nerves. For use in these affections it 
is best dissolved in chloroform or ether. When equal parts 
of chloral or menthol are heated together in a water-bath, an 
oily liquid is formed (chloral menthol), which is efficacious 
in toothache. One part of menthol to 10 of olive oil makes 
a soothing application for burns. Dissolved in collodion in 
the proportion of 1 : 4 it forms a useful dressing for small 
contusions. The inhalation of menthol in the form of a vapor 
or spray affords considerable relief from the disagreeable symp- 
toms of acute coryza. The following solution will be found 
useful in both coryza and acute laryngitis : 

R Menthol, gr. vj (0.4 gm.) ; 

Eucalyptol, TT\v (0.3 c.c); 

Petrolati liquidi, fjj (30.0 c.c). — M. 

Sig. To be used as a spray several times a day. 

Liquid petrolatum containing from 5-10 per cent, of men- 
thol makes an excellent vehicle for various remedies employed 
in the treatment of chronic rhinitis and chronic laryngitis. 

The following mixture in the form of a spray has been 
recommended as a local anesthetic in minor surgical opera- 
tions : 

R Menthol, gr. x (0.65 gm.) ; 

Chloroformi, f£v (18.5 c.c); 

yEtheris, fgj (30.0 c.c.) —M. 

Internally, menthol is sometimes used in persistent vomit- 
ing and gastralgia, but it is rarely successful. 

Ethyl Chlorid (see p. 1 29).— This compound is produced 
by the action of dry hydrochloric acid gas on absolute alcohol 
On account of the intense cold caused by its rapid evapora- 
tion it is employed as a local anesthetic. It is usually sold in 
small glass tubes, provided with a lever-spring top. When the 
lever is depressed, the liquid is expelled as a spray by the heat 
of the hand. 

Ethyl chlorid is a convenient local anesthetic for use in 
minor operations requiring but a single incision, such as opening 
boils and aspirating pleural or abdominal effusions. It is 
seldom efficient in operations upon the deeper structures 
requiring dissection or curetting. 



PHENOL— VERA TRIN. 



J 59 



As a permanent opacity may result when freezing 
come in contact with the cornea, caution must be exercised in 
using ethyl chlorid about the head (Merz-Weigandt). 

Phenol (see p. 387). — As a local anesthetic phenol acid is 
chiefly employed to allay itching in jaundice and pruritic skin 
diseases like eczema and urticaria. It may be used in the 
strength of \\-2 dr. (5.8-7.8 gm.) to the pint (0.5 L.) of water 

Iodoform (see p. 319).— On account of its analgesic prop- 
erties iodoform is a valuable topical remedy in various ulcera- 
tions of a painful character. It is particularly useful in reliev- 
ing the pain and dysphagia of tuberculous laryngitis, in which 
affection it is employed by insufflation, either in a pure form 
(2-3 gr. — 0.13-0.2 gm.) or mixed with morphin (y~S~T2 S r - — 
0.004-0.005 gm.). Suppositories of iodoform are often of 
service in painful hemorrhoids and in fissure of the anus. 

Camphorated Chloral. — This is a syrupy liquid made by 
rubbing together equal parts of camphor and hydrated chloral. 
It is soluble in alcohol, ether, glycerin, and oils, but it is de- 
composed by water. It is used as a local anesthetic in neu- 
ralgia, toothache, and pruritus. In local pruritus the following 
ointment is sometimes efficacious : 

R Pulveris c amphorae, 

Pulveris chlorali hydrati, aa gj (4.0 gm.); 

Trit. et add. 

Unguenti aquae rosae, §j (30.0 gm.). — M. 

Aconite (see p. 60). — The tincture of aconite, rubbed into 
the affected part, is sometimes useful in relieving the pain of 
neuralgia and in allaying the itching of chilblains. Ointments 
containing aconitin (5-10 gr. to the ounce — 0.3-0.6 gm. to 
30.0 gm.) are also prescribed in neuralgia, but on account of the 
extreme virulence of the alkaloid they must be used with 
great caution. Liniments containing aconite and chloroform 
are employed with benefit in muscular rheumatism. 

Veratrin is an alkaloid obtained from the seed of Asagrcea 
officinalis, a bulbous herb growing in Mexico and Central 
America. The official preparation is a mixture of pure vera- 
trin and a number of other less active alkaloids. It is a white, 
amorphous, or semicrystalline powder, odorless and intensely 
acrid. It is readily soluble in alcohol, but very slightly so in 
water. 

Veratrin has an action very similar to that of aconitin. In 
the form of the ointment {Unguentum Veratrince, U. S. P.) or 
oleate {Oleatum Veratrince, U. S. P.) it is occasionally employed 
as a local remedy in neuralgia. It should never be applied 



l60 SENSORY NERVE DEPRESSANTS. 

over large surfaces or where there are any abrasions. In em- 
ploying it about the face great care must be exercised to keep 
it out of the eye. 

Hydrocyanic or prussic acid is employed in medicine 
only in very dilute solution. The official preparation (Acidum 
Hydrocyanicum Dilutuni), a 2 per cent, aqueous solution, is a 
colorless liquid with the odor and taste of bitter almonds. 
The dose is from 1 to 3 min. (0.05-0.2 c.c). 

Hydrocyanic acid is a general protoplasmic poison. In 
moderate doses it first stimulates and then powerfully de- 
presses the central nervous system, especially the respirator)' 
vasomotor and cardio-inhibitory centers in the medulla. It 
also depresses the heart or its contained motor ganglia, and 
decreases all metabolic processes. Large doses kill almost 
immediately, the heart and respiration being arrested simul- 
taneously. After death the blood often retains for a time 
its bright red color, owing to the formation of cyanhemo- 
globin, a compound that is less readily reduced than oxy- 
hemoglobin. Hydrocyanic acid is partially destroyed in the 
tissues and partially transformed into sulphocyanides, which 
escape in the urine. Locally applied, even in dilute solution, 
it produces numbness of the part by depressing the endings 
of the sensory 7 nerves. 

Toxicology . — When death is not immediate, the character- 
istic symptoms of prussic acid poisoning are a sense of 
numbness in the mouth, salivation, dyspnea, dilatation of the 
pupils, infrequent pulse, clonic convulsions, involuntary dis- 
charge of urine and feces, unconsciousness, and collapse. 
Treatment is rarely effectual on account of the very rapid 
action of the drug. It consists in artificial respiration and the 
use of such stimulants as strychnin and atropin. Sodium 
hyposulphite has also been recommended in order to form 
an innocuous sulphocyanide. 

In the form of lotion hydrocyanic acid is sometimes used to 
relieve itching in eczema and pruritics when there is no abrasion 
of the skin. Internally, it is often of sendee in relieving gas- 
tralgia and controlling the pain and vomiting of gastric ulcer 
and cancer. It has also been used largely to allay cough 
in advanced phthisis. Dilute prussic acid is very prone to 
decomposition, and, therefore, the preparations on the market 
vary considerably in their value. The following formulae will 
illustrate the manner in which the drug may be prescribed: 

R Acidi hydrocyanici diluti, fr^ss (2.0 c.c.); 

Glycerini, fzj (4.0 c.c.); 

Aquae, q. s. ad f^ij (60.0 c.c). — M. 

Sig. Apply as directed. {Pruritus. ) 



MYDRIATICS. l6l 

Be Bismuthi subnitratis, Jfss (15.0 gm.); 

Acidi hydrocyanici diluti, ITlxl ( 2 -5 c.c); 

Aquae, q. s. ad fliv (120.0 c.c). — M. 

Sig. Shake well. A dessertspoonful before meals. ( Gastric ulcer or catarrh?) 

R Codeinse sulphatis, gr. iv (0.25 gm. ); 

Acidi hydrocyanici diluti, Ttl^xxij (2.0 c.c); 

Syrupi tolutani, q. s. ad f^ij (60.0 c.c). — M. 

Sig. A teaspoonful every four hours. [Cough of phthisis.) 

Ether (see p. 1 1 8).: — The application of ether in the form 
of a spray is one of the oldest methods of producing local 
anesthesia. The sensory nerves are benumbed by the intense 
cold which is occasioned by the rapid evaporation of the drug. 

This method may be employed preliminary to opening small 
abscesses or performing paracentesis. 



MYDRIATICS. 

The size of the pupil is regulated by the unstriped muscle- 
fibers of the iris, of which there are two sets — concentrically 
arranged constrictor fibers and radiating dilator fibers. Two 
antagonistic nerves control these muscles : the oculomotor, 
which when stimulated contracts the pupil through the agency 
of the constrictor fibers, and the sympathetic, which when stim- 
ulated dilates the pupil through the agency of the dilator fibers. 

Mydriasis or dilatation of the pupil may be brought about 
in a variety of ways : By paralyzing the oculomotor center in 
the medulla; by paralyzing the peripheral filaments of the 
oculomotor nerve ; by paralyzing the constrictor muscle of the 
iris ; by stimulating the sympathetic center in the medulla ; by 
stimulating the peripheral fibers of the sympathetic nerve, or 
by stimulating the radiating muscular fibers of the iris itself. 

All mydriatics impair more or less the accommodative power 
of the eye; that is, its power of adjusting itself to vision at 
different distances. The agency through which the adjust- 
ment is effected is the ciliary muscle. In accommodating for 
near objects this muscle contracts, the suspensory ligament 
relaxes, the lens, owing to its inherent elasticity, becomes 
more convex. Of the mydriatics, kyoscin, hyoscyamin, and 
atropin are the most powerful cycloplegics or paralyzants of the 
ciliary muscle, and cocain and euphthalmin are the least pow- 
erful. 

Another property of mydriatics is their power of increasing 
the intra-ocular tension, and so favoring the development of 
11 



1 62 MYDRIATICS. , 

glaucoma when a tendency to that affection already exists. 
Dilatation of the pupil mechanically increases the intra-ocular 
pressure by narrowing the angle between the iris and the 
cornea, thus impeding the escape of humor from the eye 
through the small openings communicating with the canal of 
Schlemm. Of the mydriatics, cocain and euphthalmin have the 
least effect on the intra-ocular tension. 

Mydriatics are employed to facilitate ophthalmoscopic ex- 
amination, to paralyze accommodation when estimating refrac- 
tive errors, to rest the iris and to prevent or break loose adhe- 
sions in iritis, to enlarge the field of vision in nuclear cataract, 
when the periphery of the lens is still clear, and to allay 
irritation in inflammation of the cornea. 

The most important local mydriatics are : 

Atropin. Hyoscin or scopolamin. 

Homatropin. Cocain. 

Methylatropin (eumydrin). Euphthalmin. 
Hyoscyamin. 

Atropin Sulphate (see p. 75). — Atropin dilates the pupil 
by paralyzing the oculomotor nerve-endings in the sphincter 
muscle of the iris, and destroys the power of accommodation 
by paralyzing the nerve-endings in the ciliary muscle. It also 
increases the intra-ocular tension. After the installation into 
the eye of a drop or two of a solution of atropin (4 gr.-i fl. 
oz. — 0.26 gm-30.0 c.c.) mydriasis begins in fifteen minutes, 
and attains its maximum in about half an hour. Accommo- 
dation is not affected so quickly, paralysis not being complete 
within an hour and a half. On the other hand, mydriasis 
persists somewhat longer than the suspension of accommoda- 
tion. The effect of an atropin solution of the strength indicated 
does not usually disappear completely for about ten days. 

Atropin may be used as a simple mydriatic to facilitate oph- 
thalmoscopic examination, but euphthalmin, cocain, and hom- 
atropin are as efficient for this purpose and cause less incon- 
venience to the patient. As it paralyzes accommodation it is 
a reliable mydriatic for general use in refraction work, but 
many ophthalmologists prefer cycloplegics which have a 
less persistent action. In iritis it is indispensable in preventing 
and in breaking up adhesions between the iris and the capsule 
of the lens. In acute keratitis it is also very useful in allaying 
ciliary irritation. 

As a simple mydriatic \ gr. (0.016 gm.) to the ounce (30.0 
c.c.) is sufficient, and the mydriasis from this solution does not 



HOMATROPIN HYDROBROMID — COCAIN HYDROCHLOR. 163 

last longer than four or five days. As a cycloplegic, a solution 
of 4 gr. (0.26 gm.) to the ounce (30.0 c.c.) should be instilled 
into the eye, one drop at a time, three times for at least a day. 
A solution of the same strength is generally used in iritis. In 
keratitis a solution containing 1-2 gr. (0.65-0.13 gm.) to the 
ounce (30.0 c.c.) will be effective. 

Homatropin Hydrobromid. — Homatropin is an artificial 
alkaloid obtained by heating tropin (a component of atropin) 
with mandelic acid, in the presence of dilute hydrochloric acid. 
It is employed in the form of the hydrobromid {Homatropince 
Hydrobrornidum, U. S. P.), which is freely soluble in water. 

Like atropin, it dilates the pupil and paralyzes accommoda- 
tion. Its action is complete within an hour, and lasts from 
two to three days. It has an advantage over atropin in the 
shorter duration of its effects. It is, however, several times 
more costly than the natural alkaloid. To paralyze the accom- 
modation a solution of 8-12 gr. (0.5-0.8 gm.) to the ounce 
(30.0 c.c.) must be instilled in the conjunctival sac six or eight 
times at intervals of five or ten minutes. In facilitating oph- 
thalmoscopic examination a solution of 1-2 gr. (0.06-0. 1 3 gm.) 
to the ounce (30.0 c.c.) is sufficient. 

Methylatropin or eumydrin has properties similar to 
those of atropin, though it is not so poisonous. As a mydri- 
atic it acts more quickly than atropin, but its effects are less 
lasting. It is applied in from 1 to 2 per cent, solution. 

Hyoscyamin (see p. 81). — This alkaloid is obtained from 
hyoscyamus and other Solanacece. It is official in the form 
of hydrobromid (Hyoscyamince Hydrobromid tun) and the sul- 
phate {Hyoscyarnino? Sulphas), both of which salts are freely 
soluble in water. Upon the eye hyoscyamin acts like atropin 
in dilating the pupil and paralyzing the accommodation, but 
its effects are less lasting, being not more than six or seven 
days in duration. Some ophthalmologists prefer it to atropin 
for this reason. It is usually employed in the strength of 2 
grains (0.13 gm.) to the ounce (30.0 c.c). 

Hyoscin or Scopolamin Hydrobromid (see p. 82). — 
This drug dilates the pupil, paralyzes accommodation, and 
increases intra-ocular tension in the same way as atropin ; but 
it acts more powerfully and quickly and its effects are of much 
shorter duration. Its chief drawback is its greater tendency 
to cause constitutional disturbance. It may be employed in 
the strength of 4 grains (0.26 gm.) to the ounce (30.0 c.c). 

Cocain Hydrochlorid (see p. 83).— The instillation into 
the eye of a few drops of a 4 per cent, solution of cocain 
causes, in from ten to fifteen minutes, in addition to local anes- 



1 64 M YDRIA TICS. 

thesia, marked dilatation of the pupil. The mydriasis attains 
its maximum in about an hour, and persists for from twelve 
to fifteen hours. It is of peripheral origin, and is probably 
caused by stimulation of the sympathetic nerves. Cocain only 
slightly impairs accommodation. In strong solutions it has 
an injurious effect upon the corneal epithelium. 

As the effect of cocain on the pupil is of short duration, 
and as it does not seriously disturb accommodation, it is a 
convenient mydriatic for retinal examinations. In iritis atropin 
is distinctly preferable on account of its forcible action and 
lasting effect. The mydriasis induced by cocain is readily 
overcome by the instillation into the eye of a few drops of a 
1 per cent, solution of eserin. Stronger solutions of cocain 
than 4 per cent, should not be used in the eye on account of 
the danger of causing degenerative changes in the corneal 
epithelium. 

Euphthalmin. — This synthetic alkaloid is the hydro- 
chlorid of the mandelic acid derivative of eucain B. It occurs 
in the form of a white crystalline powder, soluble in cold 
water. Its solution can be sterilized by boiling, and may 
thus be kept for a long time. If a few drops of a 4 per cent, 
solution be placed in the conjunctival sac, mydriasis begins in 
a few minutes, attains its maximum in about half an hour, 
and passes away within six or seven hours. While its mode 
of action has not been fully determined, it is probable that the 
drug dilates the pupil by paralyzing the peripheral ends of the 
oculomotor nerve. Euphthalmin does not injure the corneal 
epithelium; it does not irritate the conjunctiva; it gives rise 
to no constitutional disturbance ; and it only slightly impairs 
accommodation. Contrary to what has been stated, however, 
it does increase to some extent the intra-ocular tension, and 
Knapp has observed glaucoma follow the use of a 7.5 per 
cent, solution. On account of the brief duration of its action 
on the pupil, and its slight cycloplegic influence, it is perhaps 
the best agent we possess for simple ophthalmoscopic purposes. 
Solutions varying from 4 to 6 per cent, are usually employed. 
According to Jackson the following solution is more active in 
dilating the pupil and at the same time less persistent in its 
effect than a stronger solution of euphthalmin alone : 

Euphthalmin, I part ; 

Cocain hydrochlorid, I " 

Distilled water, 100 parts. 



MYOTICS. 165 

MYOTICS. 

Myosis or contraction of the pupil may result from causes 
the reverse of those mentioned as being capable of bringing 
about mydriasis. Morphin, when taken internally in large 
doses, contracts the pupil by stimulating the oculomotor center. 
Physostigmin and pilocarpui, applied quickly to the eye, cause 
contraction of the pupil by stimulating the peripheral endings 
of the oculomotor nerve, and probably also the iris muscle 
itself. Both drugs also lessen intra-ocular tension by widen- 
ing the angle between the iris and the cornea, thus favoring 
the escape of humor from the eye, and, in strong solution, in- 
duce spasm by accommodation. Arecolin apparently has a 
similar action. 

Physostigmin or Eserin Sulphate (see p. 146). — This 
is the most commonly used myotic. When a gentle, con- 
tinuous action is desired, a solution containing from \-\ gr. 
(0.008-0.065 gm.) to the ounce (30.0 c.c.) is sufficient, but 
when a prompt and powerful action is necessary, a solution 
containing from 2-3 gr. (0.13-0.2 gm.) to the ounce (30.0 c.c.) 
may be employed. The maximum effect of these solutions is 
secured in from one-half to three-quarters of an hour, and 
persists from a few hours to several days. On standing, solu- 
tions of physostigmin turn red and lose some of their effect- 
iveness. 

Pilocarpin Hydrochloric! (see p. 258). — The action of 
pilocarpin on the eye is very much like that of physostigmin, 
but less powerful. It is employed in solution of from 1-4 gr. 
(0.065-0.26 gm.) to the ounce (30.0 c.c). 

Arecolin Hydrobromid. — This is the hydrobromid of a 
liquid alkaloid obtained from areca catechu, or betel-nut. It 
is a white crystalline salt, soluble in water. In the form of \ 
or 1 per cent, solution (2J-4J gr. to the ounce — 0.14-0.3 
gm. to 30.0 c.c.) it is a powerful myotic. Contraction of the 
pupil begins in from three to five minutes, reaches its maxi- 
mum in from ten to fifteen minutes, and is accompanied by 
spasm of the ciliary muscle. The pupil returns to its normal 
condition within an hour or two. Its action is more rapid, 
but at the same time more transient, than that of physostigmin. 
Its power of lowering tension in glaucoma is apparently equal 
to that of eserin, and in Bietti's hands it proved successful in 
a case of glaucoma in which physostigmin had failed. 

Arecolin has been used with asserted success as an anthel- 
mintic, and, according to Frohner and Clemesma, it is, when 
injected hypodermically, a more powerful sialagogue than 
pilocarpin. 



1 66 EMETICS. 

EMETICS. 

Vomiting is a reflex act consisting of a forcible spasmodic 
contraction of the abdominal muscles and diaphragm. While 
the contraction of the muscular coat of the stomach may- 
assist in the act, it is not an essential factor, for Magendie 
found that when the stomach was removed and was replaced 
by a bladder filled with water, emesis could still occur. The 
afferent impulses which excite vomiting travel from the stom- 
ach through the sensory fibers of the vagus to a center in the 
medulla closely connected with the respiratory center, and 
thence the efferent impulses are conducted through the 
phrenics, the spinal nerves, and the vagus to the muscles 
concerned in the act. 

Theoretically, a drug may cause vomiting either by directly 
affecting the center in the medulla or by indirectly affecting 
it through irritation of the sensory nerve-endings in the 
stomach. It is not always an easy matter to determine the 
exact mode of action of an emetic. If the drug be injected 
into a vein, it may act directly on the vomiting center, or, being 
eliminated through the stomach, it may act reflexly by irri- 
tating the sensory nerves of that organ ; or again, if the drug 
be given by the mouth, it may irritate the stomach and pro- 
voke emesis through a reflex action, or, being absorbed, it 
may excite the vomiting center directly. If, however, a drug 
acts more promptly when injected subcutaneously than when 
it is given by the mouth, and if vomiting follows its injection 
after the stomach has been replaced by a bladder filled with 
water, or after all the arteries leading to the stomach have 
been ligated, it may be assumed that its action is chiefly a 
direct one on the center in the medulla. The action of 
apomorpliin is purely central, while that of copper sulphate, zinc 
sulphate, yellow sulphate of mercury, alum, mustard, ipecac, and 
antimony is probably entirely peripheral, although some writers 
believe that the last two drugs have some direct influence on 
the medulla. 

Emetics may be employed for one of three purposes : To 
expel irritating food or poisons from the stomach ; to expel 
foreign bodies, false membrane, or excessive secretion from 
the respiratory tract ; and to expel mucus and bile from the 
gall-ducts in catarrhal jaundice. 

Emetics should be avoided or used with extreme caution in 
advanced pregnancy and in persons suffering from aneurysm, 
atheroma, or hernia. 

Apomorphin Hydrochloric! (see p. 273).— This drug is 



IPECA CUANHA -MERCl 'R \ ' SUBSULPHA TE. 1 67 

the most prompt and reliable emetic that we possess ; more- 
over, it causes little nausea, and it is effective when admin- 
istered hypodermically. It is very useful in poiso?iing, espe- 
cially when swallowing is impossible, or when the state of the 
stomach is such as to prohibit the use of a mechanical or 
irritant emetic. In acute alcoholism it is exceedingly effectual. 
In some cases of narcotic poisoning, on account of the 
decreased sensitiveness of the medullary center, apormorphin, 
like other emetics, may prove inactive. As an emetic the 
drug should be administered hypodermically, although it will 
provoke vomiting when given by the mouth if the dose be 
sufficiently large. It must be borne in mind that in the very 
young and infirm considerable depression may attend its action. 
The dose is from T V~ ir § T - (0.005-0.01 gm.). Solutions are 
most conveniently prepared from tablets containing the requisite 
dose. Both tablets and solution are liable to deteriorate with 
age and on exposure to light and air. 

Ipecacuanha (see p. 269). — This drug is a safe and fairly 
prompt emetic. Its action is not so vigorous or so depressing 
as that of the mineral emetics. It is especially adapted for 
children, in whom it may be employed to unload the stomach 
of irritant food or to expel tenacious mucus from the air- 
passages. The syrup and the wine are eligible preparations, 
and either may be given to children in doses of from \-2 fl. 
dr. (2.0-8.0 ex.). 

Tartar Emetic (see p. 271;. — The use of antimonial prepa- 
rations as emetics is fortunately obsolescent. As their action 
is slow and is attended with prolonged nausea and depression, 
apomorphin, ipecacuanha, zinc sulphate, or mustard should 
always be selected in their stead. 

£inc Sulphate (see p. 367). — As an emetic zinc sulphate 
is employed chiefly in narcotic poisoning. The dose is from 
10-30 gr. (0.65-2.0 gm.), repeated in fifteen or twenty minutes, 
if necessary. 

Copper Sulphate (see p. 366). — This drug is a more 
prompt and powerful emetic than zinc sulphate. In phos- 
phorus poisoni?ig it serves a double purpose : it not only 
unloads the stomach, but it also acts as a partial antidote by 
coating the phosphorus with an insoluble phosphid of copper. 
The dose of copper sulphate is from 5-10 gr. (0.3-0.65 gm.), 
and when this amount has been administered without effect, 
it is best not to repeat it, but to resort to some other emetic. 

Mercury Subsulphate (Turpeth Mineral). — This drug 
was formerly used in doses of 2-3 gr. (o. 1 3-0.2 gm.) as an 
emetic in croup. Although certainty, quickness of action, 



1 68 ANTI-EMETICS. 

tastelessness, and small bulk are in its favor, it cannot be 
recommended on account of its exceedingly irritant properties. 

Alum. — Powdered alum is a safe but somewhat uncertain 
emetic. It may be given to children in doses of a teaspoonful, 
in syrup, and repeated once or twice if vomiting does not 
ensue. 

Mustard. — Mustard flour is a prompt and energetic emetic. 
It may replace zinc sulphate or copper sulphate in narcotic 
poisoning. It is contraindicated when there is acute gastritis. 
The dose is a tablespoonful stirred up in a glass of water, and 
repeated in ten or fifteen minutes if necessary. 



ANTI-EMETICS. 

The treatment of vomiting must be modified according to 
the cause. In the vomiting of intestinal obstruction it is only 
in rare instances that anything short of operative interference 
brings relief. Severe vomiting is sometimes an early mani- 
festation of chronic Bright's disease, and when such is the 
case, gastric sedatives are of little avail ; our main reliance 
must be on eliminant measures. Reflex vomiting is not un- 
common, and may be associated with lesions in various parts 
of the body, as the bowel, gall-bladder, kidney, lung, internal 
ear, or the uterus or its appendages. In this type of vomiting 
treatment, to be really curative, must be directed to the orig- 
inal cause. 

The exact etiology of the vomiting of pregnancy is still 
undetermined, and hence its treatment must be in a measure 
empiric. There is a growing conviction, however, that hyper- 
emesis gravidarum is dependent upon several co-operative 
factors, the most important of which are the presence in the 
blood of irritant toxins ; reflex irritation from uterine displace- 
ment or from inflammatory lesions of the uterus or its append- 
ages ; circulatory disturbances in the medulla ; and, finally, in 
certain cases, a neurotic or hysteric element. In this form of 
vomiting remedies directed solely to the stomach generally 
prove ineffective. To rid the body of noxious materials warm 
baths, mild laxatives, and saline injections into the bowel or 
under the skin are useful remedies. Saline transfusions are 
particularly efficacious in that they dilute the poisons circu- 
lating in the blood, increase elimination, serve to maintain the 
arterial pressure, and help to nourish the patient. Pelvic irri- 
tation should receive careful attention. In some cases drugs 



ANTI-EMETICS. 1 69 

that raise the arterial pressure on the medulla, like strychnin, 
act beneficially; in others, vasodilators, like nitroglycerin, give 
better results. Drugs that directly depress the vomiting center 
are sometimes serviceable ; chloral and bromids are the best 
of this class ; morphin, as a rule, is badly borne. In neurotic 
subjects firmness tempered with kindliness and encouragement 
is essential to success. When the hysterical element is very 
pronounced, the Weir-Mitchell treatment can be recommended 
with considerable confidence. 

When the measures which have been indicated, after a 
thorough trial prove futile, and the life of the patient is 
jeopardized by the incessant vomiting, there ought to be no 
question in the mind of the practitioner as to the advisability 
of terminating the pregnancy. 

A curious form of vomiting is that which is known, for want 
of a better name, as nervous vomiting. It is not associated 
with any anatomic lesion of the stomach or with changes in 
the quantity or quality of the food, nor is it apparently of reflex 
character. In many instances it is evidently a symptom of 
hysteria. In this condition anti-emetics — cerium oxalate, 
menthol, hydrocyanic acid, and bismuth — are sometimes useful, 
but they more often fail. Suppositories of valerian, asafetida, 
and belladonna may prove efficacious. Lavage followed by 
the administration of silver nitrate (gr. \ — 0.016 gm.) often 
serves to allay the irritability of the gastric nerves. Hot com- 
presses, sinapisms, or blisters over the epigastrium are indi- 
cated. A spray of ethyl chlorid along the spine and over the 
stomach has given good results. Galvanism with a current 
of low density, one pole (negative) over the back of the neck 
and the other (positive) within the stomach, may afford prompt 
relief. In many cases it is necessary to keep the patient per- 
fectly quiet in the recumbent position, and to feed exclu- 
sively by the rectum. In intractable cases the Weir-Mitchell 
treatment should be given a thorough trial. 

Vomiting dependent upon cancer of the stomach is some- 
times controlled temporarily or lessened by anti-emetics. 
Cerium oxalate, ice-cold carbonated water, chloroform, hydro- 
cyanic acid, and bismuth may be tried. Morphin hypoder- 
mically or by the rectum is also useful. When there is ob- 
struction of the pylorus, lavage is of great service. 

When the vomiting of ulcer is not relieved promptly by 
gastric sedatives, the patient should be kept at complete rest 
for a few days and nourished by rectal injections. Counter- 
irritation by means of small blisters over the epigastrium is 
useful. Inhalations of vinegar will often allay the nausea and 
vomiting resulting from etherization. 



I70 GASTRIC ANTACIDS. 

From the foregoing it is evident that while anti-emetics are 
often exceedingly useful, they should be regarded as only 
palliative remedies or as adjuvants to more important curative 
measures. Anti-emetics may accomplish their purpose directly 
by acting on the center in the medulla, or indirectly by allay- 
ing irritability of the sensory nerve-endings in the stomach. 
To the first class belong: 

Opium. Bromids. Hydrated Chloral. 

To the second class belong : 

Carbonated water. Chloroform. 

Ice. Silver nitrate. 

Bismuth subnitrate. Menthol. 

Hydrocyanic acid. Lime-water. 

Carbolic acid. Ipecac (minute doses). 

Cocain. Cerium oxalate. 

All these agents, with the exception of cerium oxalate, are 
considered under other headings. 

CERII OXALAS, U. S. P. 

(Cerium Oxalate ; Ce 2 (C 2 4 ) 3 -f 9H 2 0.) 

Cerium oxalate is a white, odorless, and tasteless powder, 
insoluble in water or alcohol. In doses of from 6 to 15 gr. 
(0.3-1.0 gm.), preferably in the form of a dry powder, it is a 
very useful anti-emetic, acting mechanically, like bismuth subni- 
trate, by coating the wall of the stomach. It is not absorbed 
from the gastro-intestinal tract and is non-toxic. 

It has been chiefly employed against the vomiting of preg- 
nancy ; but it is far more efficacious in allaying vomiting 
caused by irritation of the mucous membrane of the stomach, 
such as occurs in gastritis, gastric ulcer, and gastric cancer. A 
combination like the following is often effective : 

j£ Cerii oxalatis, 

Bismuthi subnitratis, aa sjiss (6.0 gm.) ; 

Pulveris ipecacuanha, gr. iij (0.2 gm.). — M. 

Ft. chat-tube No. xii. 
Sig. one powder every hour. 



GASTRIC ANTACIDS. 

Gastric antacids are drugs employed to neutralize acidity 
of the stomach-contents. Some drugs, like the carbonate 
and bicarbonate of sodium, have the power of lessening not 
only the acidity of the stomach-contents, but also that of the 



SOD II BICARBONAS. 171 

urine. Others, like ammonia and ammonium carbonate, serve 
as antacids in the stomach, but are eliminated in such a form 
that they have no influence on the reaction of the urine. 
Again, there are other drugs, like the vegetable salts of potas- 
sium and lithium, which have very little effect upon the acidity 
of the stomach, but, being eliminated as alkaline carbonates, 
render the urine less acid. 

Gastric antacids are employed to neutralize the organic 
acids (lactic, butyric, and acetic) resulting from fermentation 
of the stomach-contents, and which excite eructations, heart- 
burn, and gastralgia ; to lessen the acidity in cases of hyper- 
chlorhydria ; and to antagonize poisons of an acid character. 

It is generally believed that alkalies and alkaline carbonates, 
when taken before meals, stimulate gastric secretion, but the 
experiments of Reichmann and others have clearly shown that 
they produce no such effect. What efficacy they have in mild 
derangement of digestion is to be attributed to their power of 
neutralizing excessive acidity, dissolving tenacious mucus, and 
stimulating the stomach wall itself. 

The most important antacids are : 

Sodium bicarbonate. Magnesium carbonate. 

Lime-water. Calcium carbonate. 

Magnesia. Ammonia. 

SODII BICARBONAS, U. S. P. 

(Sodium bicarbonate; NaHC0 3 .) 

Sodium bicarbonate is a white, opaque, odorless powder, 
having a cooling, faintly alkaline taste. It is soluble in 12 
parts of water and insoluble in alcohol. The dose is from 
5-3° g r - (0.3-2.0 gm.). 

Preparations. Dose. 

Mistura Rhei et Sodae, U. S. P 1-2 fl. dr. (2.0-8.0 c.c). 

Pulvis Effervescens Compositus (Seidlitz Powder), U. S. P. 

Trochisci Sodii Bicarbonatis, U. S. P., contain z\ gr. (0.18 gm.) each. 

Therapeutics. — Sodium bicarbonate is extensively used 
in diseases of the stomach to neutralize abnormal acids or 
hydrochloric acid when in excess. Given before meals in 
small doses (3-5 gr. — 0.2-0.3 gm.), with some bitter stomachic, 
it often affords prompt relief in mild forms of indigestion. Given 
an hour or two after meals it allays the burning pain, eructa- 
tions, and palpitation due to the acids of fermentation. Given 
at the height of digestion in large doses it relieves the painful 



172 GASTRIC ANTACIDS. 

crises of hyperchlorhydria. Large doses of sodium bicarbonate 
are also useful in neutralizing the hydrochloric superacidity 
encountered in gastric ulcer. In the chronic gastro-intestinal 
catarrh of childhood, characterized by capricious appetite, 
tympanites, eructations, troubled sleep, and hard, lumpy, 
mucous stools, sodium bicarbonate with a bitter and a mild 
laxative often gives excellent results. 

In daily doses of from 5-10 dr. (20.0-40.0 gm.) it has been 
employed successfully by Huchard and others in averting 
diabetic coma. In fully developed coma the drug should be 
given intravenously in 3 to 5 per cent, acid solution to the 
extent of one or two pints. The subcutaneous injection of 
alkaline solutions should be avoided, as not rarely they cause 
sloughing. 

Sodium bicarbonate is sometimes used externally as a seda- 
tive dressing in superficial burns. A 5 to 10 per cent, solu- 
tion is an excellent remedy for thrush. It is employed as a 
detergent in many washes designed for chronic catarrhal affec- 
tions of the nasopharynx ', and it is an ingredient of the well- 
known Dobell's solution, which may be prescribed as follows : 

ij Sodii bicarbonatis, 

Sodii boratis, aa gj (4.0 gm.) ; 
Phenolis, gr. xxx (2.0 gm.) ; 

Glycerini, f!|j (30.0 c.c.) ; 

Aquae, Oij (1.0 L.). — M. 

Sodium bicarbonate is incompatible with acids, metallic 
salts, and alkaloids. 

LIQUOR CALCIS, U. S. P. 

(Solution of Calcium Hydroxid ; Lime-water.) 

Lime-water is a saturated aqueous solution of calcium 
hydroxid made by slaking lime with water. It is a clear, color- 
less liquid, odorless, and having a saline, slightly caustic taste. 
It contains about 0.17 per cent, of calcium hydroxid. The dose 
is from -1—2 fl. oz. (15.0-60.0 c.c). 

Preparations. 
Linimentum Calcis, U. S. P. (lime liniment, Carron oil), contains 

equal volumes of lime-water and linseed oil. 
Lotio Hydrargyri Flava (yellow-wash), \ dr. (2.0 gm.) of corrosive 

sublimate to I pint (o. 5 L. ) of lime-water. 
Lotio Hydrargyri Nigra (black-wash), I dr. (4.0 gm. ) of calomel 

to I pint (0.5 L.) of lime-water. 

Therapeutics. — In all conditions in which cows' milk is 
the chief article of diet, lime-water may be added to the milk, 
to prevent the formation in the stomach of hard curds. 



OTHER ANTACIDS. 1 73 

In the diarrhea of children and in typhoid fever it is especially 
useful when employed in this way. It is sometimes a useful 
remedy in obstinate vomiting, particularly when the latter is 
due to a high degree of acidity. In chronic gastric catarrh 
with excessive secretion of mucus, washing out the stomach 
with a weak solution of lime-water (i : 10) before breakfast 
may be practised with great benefit. 

Inhalations of atomized lime-water have been recommended 
for their solvent effect in diphtheria and fibrinous bronchitis. 
As an alkaline astringent lime-water is sometimes employed 
as an injection in vaginitis, leucorrhea, and urethritis. It may 
be used also as an injection in seat-worms, although it is in- 
ferior to an infusion of quassia. Carron oil is used as a soothing 
application for burns and scalds. It has received its name 
from being so extensively used by the workmen in the found- 
ries at Carron, Scotland. 



OTHER ANTACIDS- 

Magnesia (see p. 199).' — Magnesia or magnesium oxid is 
official in two forms : light or calcined magnesia {Magnesii 
Oxiduni) and heavy magnesia {Magnesii Oxidum Po?iderosuni). 
Both forms occur as white, insoluble powder, odorless, and 
having a slightly earthy taste. Heavy differs from light mag- 
nesia not only in its weight, but also in its not readily uniting 
with w r ater to form a gelatinous hydroxid. The dose of either 
oxid is from 10-60 gr. (0.65-4.0 gm.). 

Magnesia combines the usefulness of an antacid with that 
of a mild laxative. When there is constipation, it may be 
given instead of sodium bicarbonate or combined with that 
drug in all conditions in which an antacid is indicated. In the 
diarrhea of childhood, when there is unnatural acidity of the 
prima? vice, it is an excellent laxative for removing sour, indi- 
gestible food. In ulcer of the stomach it may be advantageously 
combined with bismuth to control constipation. 

Magnesium Carbonate (see p. 200). — This drug is used 
in the same doses and for the same purposes as magnesia. 

Calcium Carbonate (see p. 377). — Calcium carbonate or 
chalk is an unirritating antacid and a feeble astringent. It 
is very useful in diarrhea with acidity of the pri?nce via?, and 
it may be combined with bismuth subnitrate in the treatment 
of gastric ulcer when there is a marked tendency to looseness 
of the bowels. It is a chemical antidote to all the poisonous 
acids. 



174 STOMACHICS. 

Ammonia (see p. 41). — Aromatic spirit of ammonia, in 
doses of from 20-30 min. (1.2-2.0 c.c), may be used instead 
of sodium bicarbonate to relieve the headache, heart-burn, 
and pyrosis arising from acid fermentation in the stomach. 



STOMACHICS. 

Stomachics are drugs which sharpen the appetite and pro- 
mote the functional activity of the stomach. The most im- 
portant members of this class of remedies are : 

Gentian. Condurango. 

Quassia. Taraxacum. 

Calumba. Eupatorium. 

Nux vomica. Serpentaria. 

Cinchona. Cascarilla. 

Chirata. Wild cherry. 

Chamomile. Alcohol. 

Hydrastis. Orexin. 

All stomachics, with the exception of the last two in the fore- 
going list, contain a bitter principle. Taken by the mouth, 
bitters improve the appetite, and, by stimulating the gustatory 
nerve-endings, reflexly increase the salivary and gastric secre- 
tions. Being more or less irritant to the mucous membrane 
of the stomach and bowel, they also augment the peristaltic 
movements. With the exception of cinchona and nux vomica, 
which have important constitutional actions, they probably 
exert no direct influence beyond the digestive organs. To be 
effective, they should be taken in liquid form a short time 
before eating As a class, stomachics are useful in atony of 
the stomach, in chronic gastritis when the mucous membrane 
is not very irritable, and in the early stages of cancer. They 
are contraindicated in all conditions involving the stomach in 
which there is marked irritability or hypersecretion. 

GENTIANA, U. S. P. 

(Gentian.) 

Gentian is the root of Gentiana lutea, a perennial herb 
growing in the mountainous districts of Central and Southern 
Europe. It contains an extremely bitter glucosid, gentio- 
picrin, and gentisic or gentianic acid, which is inert. 



QUASSIA— CALUMB A. 1 75 



Preparations. Dose. 

Tinctura Gentianae Composita, U. S. P. ] 

(contains also bitter orange-peel and 1 1-2 fl. dr. (4.0-8.0 c.c). 

cardamom) ' J 
Fluidextractum Gentianae, U. S. P. . . . 10-30 min. (0.6-2.0 c.c.). 
Infusion Gentianae Compositum .... $-2 fl. oz. (15.0-60.0 c.c). 
Extractum Gentianae, U. S. P 2-5 gr. (0.13-0.3 gm.). 



Therapeutics. — Gentian is one of the most reliable of the 
bitter tonics. It is often of great value in the milder forms of 
chronic indigestion, in the dyspepsia of phthisis, and in the early 
stages of cancer. It is an excellent restorative in the conva- 
lescence of acute fevers. In indigestion it may be advantage- 
ously combined with an alkali, as in the following formula : 

R Sodii bicarbonatis, ^ij (8.0 gm.) ; 

Infusi gentianse compositi, f^vj (180.0 c.c). — M. 

Sig. A tablespoonful before meals. 

QUASSIA, U. S. P. 

Quassia is the wood of Picrasma excelsa, or of Quassia amara, 
a tree resembling the common ash, growing in the West Indies. 
It contains a bitter crystalline principle, quassin, but no tannic 
acid. The dose of quassin is from ^— \ gr. (0.002-0.02 gm.). 

Preparations. Dose. 

Tinctura Quassiae, U. S. P ^-1 fl. dr. (2.0-4.0 c.c). 

Fluidextractum Quassiae, U. S. P. . . 10-20 min. (0.6-I.2 c.c). 

Extractum Quassiae, U. S. P 1-3 gr. (0.06-1. 2«gm.). 

Infusion Quassiae \-2 fl. oz. (15.0-60.0 c.c). 

Therapeutics. — As a stomachic, quassia may be used in 
the same class of cases as gentian. 

The rectal injection of an infusion made by adding an ounce 
(31.0 gm.) of quassia chips to a pint (0.5 L.) of water is an effi- 
cient anthelmintic against seat-worms (Oxyuris vermicularis). 
To secure the best results the bowel should first be thoroughly 
cleansed by means of a simple soap-and-water enema. 

As quassia does not contain tannic acid, its preparations are 
not incompatible with the salts of iron. 

CALUMBA, U. S. P. 

(Columbo.) 

Calumba is the root of Jateorhiza palmata, growing in 
Eastern Africa. It contains an alkaloid, berberin, a neutral 
principle, columbin, and columbic acid, all of which are bitter. 

Preparations. Dose. 

Tinctura Calumbse, U. S. P i-2 fl. dr. (2.0-8.0 c.c). 

Fluidextractum Calumbae, U. S. P. . . 10-30 min. (0.6-2.0 c.c). 

Extractum Calumbae 2-5 gr. (o. 13-0.3 gm.). 

Infusum Calumbae £-2 fl. oz. (15.0-60.0 c.c.). 



176 STOMACHICS. 

Therapeutics. — Calumba is a pure, unirritating bitter, and 
may be prescribed with confidence in the various conditions 
in which stomachics are indicated. It may be combined with 
either acids or alkalies, and since it contains no tannin, it does 
not form a black, unsightly mixture with the salts of iron. In 
atony of the stomach it may be combined witn nux vomica, 
as in the following formula : 

R Tincturae capsici, TTLxvj (i.oc.c). 

Tincturae nucis vomicae, f^ij (8.0 c.c). 

Tiincturae calumbae, q. s. ad f^ij (60.0 c.c). — M. 
Sig. A teaspoonful in water before meals. 

CHIRATA, U. S. P. 

(Chiretta.) 

Chirata is the entire plant of Swertia chirayita, growing in 
the mountains of Northern India. It contains a bitter crystal- 
line glucosid, chiratin, and ophelic acid, which is also bitter. 

Preparations. Dose. 

Fluidextractum Chiratae, U. S. P.' . . . 10-30 min. (0.6-2.0 c.c). 

Tinctura Chirata? £-1 fl. dr. (0.2-4.0 c.c). 

Infusion Chiratae £-2 fl. oz. (15.0-60.0 c.c). 

Therapeutics. — In addition to its virtues as a bitter stom- 
achic, chirata is supposed to possess decided cholagogue prop- 
erties. It is useful in those forms of indigestion which are 
associated with so-called bilious attacks. Like quassia and 
calumba, it is free from tannic acid ; it is therefore not incom- 
patible with iron salts. 

ANTHEMIS, U. S. P. 

(Chamomile.) 

Chamomile is the flower-heads of Anthemis nobilis, a per- 
ennial plant cultivated in Western Europe, and to some extent 
in the United States. It contains a volatile oil, a bitter prin- 
ciple, anthemin, and a small amount of tannin. Chamomile 
is a mild stomachic and carminative, and is usually employed 
in the form of an infusion (unofficial), of which 1-2 fl. oz. 
(30.0-60.0 c.c.) may be givea 

CONDURANGO. 

Condurango is the bark of Gonolobus Condurango, a climb- 
ing vine indigenous to Ecuador. It contains tannin and one 
or two bitter glucosids. It is usually employed in the form 
of the fluid extract in doses of from 20-60 min. (1.2-4.0 c.c). 

Therapeutics. — Condurango was first recommended by 



TAR AX A CUM—E UP A TORIUM. 1 7 7 

Friedreich in 1874 as a curative remedy in cancer of the 
stomach. Later, Immermann and Riess reported cases in 
support of this view ; but the testimony of numerous impar- 
tial observers has proved conclusively that the drug is with- 
out specific action. Notwithstanding the adverse opinion as 
to its curative power, nearly all who have used the drug agree 
that it often acts most beneficially on the concomitant catarrh, 
sharpening the appetite, lessening the pain, and promoting 
digestion. In some cases of simple gastric catarrh it is also 
efficacious. It may be prescribed with hydrochloric acid, as 
in the following formula: 

R Acidi hydrochlorici diluti, fjiss (6.0 c.c); 

Fluidextracti condurango, 

Glycerini, aa fzvj (22.5 c.c); 

Vini xerici, q. s. ad fjfiv (120.0 c.c). — M. 

Sig. A dessertspoonful in water after meals. 

TARAXACUM, U. S. P. 

(Dandelion.) 

Taraxacum is the root of Taraxacum officinale, growing 
in Europe and North America. It contains a crystalline bitter 
principle, taraxacin. 

Preparations. Dose. 

Fluidextractum Taraxaci, U. S. P. . „ . . £—2 fl. dr. (2.0-8.0 c.c). 
Extractum Taraxaci, U. S. P 5-30 gr. (0.3-2.0 gm.). 

Therapeutics. — Taraxacum is a mild stomachic, possess- 
ing feeble laxative properties. 

EUPATORIUM, U. S. P. 

(Boneset; Thoroughwort.) 

Eupatorium is the leaves and flowering tops of Eupatorium 
perfoliatum, a perennial plant growing in North America. It 
contains a bitter crystalline glucosid, eupatorin, tannin, and a 
volatile oil. 

Preparations. Dose. 

Fluidextractum Eupatorii, U. S. P. . . £-1 fl. dr. (2.0-4.0 c.c). 
Infusion Eupatorii 1-4 fl. oz. (30.0-120.0 c.c). 

Therapeutics. — Eupatorium is employed as a stomachic 
and diaphoretic. Large doses excite vomiting and purging. 
The infusion, taken while hot, has long been a popular house- 
hold remedy in colds and muscular rheumatism, 
12 



1^8 STOMACHICS. 

SERPENTARIA, U. S. P. 

(Virginia Snakeroot.) 

Serpentaria is the rhizome and roots of Aristolochia Serpen- 
taria, a perennial herb growing in the woods of the Eastern 
and Southern United States. It contains a bitter principle, 
aristolochin, a resin, tannin, and a volatile oil. 

Preparations. Dose. 

Tinctura Serpentariae, U. S. P. \-2 fl. dr. (2.0-8.0 c.c). 

Fluidextractum Serpentariae, U. S. P. . . . 10-30 min. (0.6-2.0 c.c). 
Tinctura Cinchonee Composita, U. S. P., con- 
tains 2 per cent, serpentaria 1-4 fl. dr. (4.0-15.0 c.c). 

Infusum Serpentariae £-2 fl. oz. (15.0-60.0 c.c). 

Therapeutics. — Serpentaria is believed to possess, in addi- 
tion to its properties as a bitter tonic, the power of increasing 
the secretions, especially the sweat and the urine. Large 
doses are capable of causing nausea and vomiting. Serpen- 
taria has been extensively employed as a stomachic in atonic 
dyspepsia, and, combined with more potent remedies, like nux 
vomica and cinchona, as a tonic in the convalescent stage of 
acute fevers. Garrod believes it to be a remedy of some 
power in chronic rheumatism. 

CASCARILLA. 

Cascarilla is the bark of Croton Eleuteria, a shrub growing in 
the Bahama Islands. It contains a bitter principle, cascarillin t 
a volatile oil, a resin, and tannin. 

Preparations. Dose. 

Tinctura Cascarillae |— 2 fl. dr. (2.0-8.0 c.c). 

Fluidextractum Cascarillae 10-30 min. (0.6-2.0 c.c). 

Infusum Cascarillae \-z fl. oz. (15.0-60.0 c.c). 

Extractum Cascarillae 5-10 gr. (0.3-0.65 gm.). 

Therapeutics. — The action of cascarilla resembles some- 
what that of serpentaria. For two centuries it was a favorite 
remedy in Germany and France in low fevers, diarrhea, and 
dysentery. At present it is rarely employed except as a bitter 
tonic. Mineral acids should not be given with the tincture or 
the fluid extract, since they precipitate the resin. 

PRUNUS VIRGINIANA, U. S. P. 

(Wild Cherry.) 

Prunus virginiana is the bark of Prunus serotina, a large 
tree growing in North America. It contains tannic acid, a 



OTHER STOMACHICS. 1 79 

bitter principle, a non-crystalline glucoside — amygdalitis and a 
ferment — emulsin. Hydrocyanic acid is formed from the 
union of the last two constituents in the presence of water. 

Preparations. Dose. 

Fluidextractum Pruni Virginianae, U. S. P. . . £-1 fl. dr. (2.0-4.OC.C.). 

Syrupus Pruni Virginianae, U. S. P 1-4 fl. dr. (4.0-15.0 c.c). 

Infusum Pruni Virginianae, U. S. P ^-2 fl. oz. (1 5.0-60.0 c.c). 

Therapeutics.— Wild cherry is a bitter tonic and a feeble 
nerve-sedative. It has been extensively employed in phthisis 
to allay irritable cough, its efficacy being attributed to the 
hydrocyanic acid. The amount of acid present, however, is 
so small that it can scarcely be of therapeutic value. It has 
also been used on the recommendation of Allbutt to combat 
the dyspnea and dyspepsia of heart-disease, but Allbutt him- 
self admits that it is only in the very early stages of the dis- 
ease that it exerts any decided influence. On account of its 
agreeable taste it is an excellent vehicle for unpalatable drugs. 

OREXIN. 

( Phenyl-dihydro-chin-azolin.) 

Orexin is a complex synthetic compound derived from 
chinolin. The tannate of orexin being freest from irritating 
properties is the best preparation for medicinal use. This salt 
appears as a yellowish- white, odorless powder, having a chalky 
taste. It is insoluble in water, but readily soluble in dilute 
hydrochloric acid. The dose is from 5-8 gr. (0.3-0.5 gm.), in 
capsules or tablets. 

Therapeutics. — Orexin possesses the power to a certain 
extent of sharpening the appetite, stimulating the secretion of 
hydrochloric acid, and increasing the motor activity of the 
stomach. It is sometimes useful in restoring the appetite in 
the early stages of phthisis, in chlorosis, in neurasthenia, and in 
convalescence from acute diseases. Penzoldt and Hermann! 
have spoken very favorably of it in the vomiting of pregnancy. 
It is contraindicated in organic diseases of the stomach — 
cancer, ulcer, and gastritis — and in cases of hyperacidity. 

It should be given two or three times a day, two hours 
before meals, and followed by a draft of half a glass of 
water. 

OTHER STOMACHICS. 

Alcohol (see p. 43). — In small quantities dilute alcohol 
augments the flow of the gastric secretion, stimulates the 
peristaltic movements, and accelerates absorption. Large 
amounts retard digestion. In the form of light claret, dry 



l8o DIGESTANTS. 

sherry, or whisky, it is often of service in dyspepsia associated 
with atony in the stomach, particularly in old persons ; but the 
greatest caution is necessary in ordering it on account of the 
danger of inducing the alcohol habit. All alcoholic prepara- 
tions are contraindicated when there is hyperesthesia of the 
stomach or hypersecretion of acid. 

Nux Vomica (see p. 141). — On account of its general 
tonic properties nux vomica has a decided advantage over 
many other bitters. It not only sharpens the appetite and 
increases secretion, but it probably has more effect than any 
other stomachic on the muscular movement of the stomach 
and intestines. In chronic i?idigestion, when there are no evi- 
dences of decided irritation, it is often very efficient. In dila- 
tation of the stomach the result of atony it is our most valuable 
drug, and should be given in full doses. It is also useful in 
those cases of marked flatulence, common in elderly people, 
and dependent upon a lack of tone in the walls of the stomach 
and bowel. 

Cinchona (see p. 415). — Cinchona to a certain extent shares 
with nux vomica the advantage of being a general tonic as well 
as a stomachic. The compound tincture of cinchona (Hux- 
ham's tincture) is specially serviceable as a bitter tonic in the 
convalescence of acute febrile diseases. The indigestion re- 
sulting from overwork is often promptly relieved by a combi- 
nation of quinin in small doses with nux vomica, as in the 
following formula : 

R . Quininse sulphatis, gr. x (0.65 gm.) ; 

Ferri lactatis, gr. xx (1.3 gm.); 

Extracti nucis vomicae, gr. v (0.3 gm.) ; 

Pulveris ipecacuanhae, gr. iij (0.2 gm.) ; 

Oleoresinae capsici, gr. ij (0.13 gm.). — M. 

Fiant pilulae No. xx. Sig. One after meals. 

Hydrastis (see p. 379). — Hydrastis is a useful bitter tonic 
in asthenic gastritis with motor insufficiency. In addition to 
its virtues as a stomachic, it is an active stimulant to intestinal 
peristalsis. According to the researches of Rutherford and 
of Cerna, it increases the flow of bile. The drug may be 
employed in the form of the fluid extract (|— I fl. dr. — 2.0- 
4.0 c.c.) or of its chief alkaloid, hydrastin (-|— \ gr. — 0.0 1 - 
0.03 gm.). 

DIGESTANTS. 

Of the agents which take part in the process of natural 
digestion the most important from the standpoint of the thera- 
peutist are hydrochloric acid, pepsin, and the enzymes contained 



ACIDUM HYDROCHLORICUM. l8l 

in the pancreatic secretion — trypsin, amylopsin, and steapsin. 
Hydrochloric acid, the natural acid of the stomach, is the most 
valuable of all digestants. It aids digestion not only directly, 
but also indirectly by stimulating the activities of the stomach, 
by preventing fermentation, and by assisting in the conversion 
of pepsinogen into the active pepsin and of labzymogen into 
the active labferment. As a remedy, hydrochloric acid is 
indicated in all conditions associated with inacidity or marked 
hypoacidity. 

Pepsin, being absent from the gastric juice far less frequently 
than hydrochloric acid, is distinctly less useful as a remedy 
than the latter. It is of service, however, in conditions asso- 
ciated with apepsia or hypopepsia, such as the advanced 
stages of chronic gastritis, atrophy of the gastric glands, and 
carcinoma. 

Of the pancreatic enzymes, trypsin digests proteids, amy- 
lopsin acts upon starches, and steapsin decomposes fats. 
Since these enzymes act best in alkaline or neutral solutions, 
and the contents of the stomach are naturally acid, it is 
argued by some authorities that artificial pancreatic extracts 
can possess no medicinal value ; but it should be remembered 
that the contents of the stomach do not normally become 
acid until from ten to fifteen minutes after the ingestion of the 
food, that in indigestion the secretion of acid is often delayed, 
and that at least one of the constituents of the pancreatic 
secretion — trypsin, a more powerful proteolytic enzyme than 
pepsin — retains its effectiveness even in solutions that are 
somewhat acid. 

The digestants in common use are : 

Hydrochloric acid. Pancreatin. Pepsin. 

Diastase. Papayotin. 

ACIDUM HYDROCHLORICUM, U. S. P. 

(Hydrochloric or Muriatic Acid ; HC1.) 

The official acid is a colorless, fuming liquid, of a pungent 
odor and an intensely acid taste. It contains 31.9 per cent, 
by weight of absolute hydrochloric acid. The dose is from 
3-6 min. (0.2-0.4 c.c.) well diluted. 

Preparation. Dose. 

Acidum Hydrochloricum Dilutum, U. S. P., 
contains 10 per cent, of absolute hydrochloric 
acid 5-20 min. (0.3-1.2 c.c). 



1 82 DIGESTANTS. 

Toxicology. — In overdoses, hydrochloric acid, like other 
mineral acids, acts as an irritant poison, causing intense burn- 
ing pain, vomiting and purging of mucous and bloody mate- 
rial, and collapse. The treatment consists in antagonizing the 
poison by soda, lime, chalk, soap, or other alkalies ; in pro- 
tecting the stomach by demulcents ; in combating collapse 
with diffusible stimulants, administered hypodermically ; and 
in relieving pain with morphin. 

Therapeutics. — Hydrochloric acid is useful in certain 
conditions of the stomach associated with inacidity or hypo- 
acidity, such as chronic asthenic gastritis, atrophy of the gastric 
glands, and cancer of the stomach. It is contraindicated, even 
though the normal acid is wanting, when there is any evidence 
of active inflammation. In the continued fevers it sometimes 
acts beneficially as a refrigerant and digestant, the gastric 
juice in these cases being generally deficient. 

The strong acid is sometimes employed externally as an 
eschar otic. 

Administration. — In indigestion the acid should be given 
after meals, well diluted, care being taken to rinse the mouth 
thoroughly after its exhibition. It may be prescribed with a 
bitter tonic, as in the following formula : 

R. Strychninse sulphatis, gr. j (0.065 gm.) ; 

Acidi hydrochlorici diluti, fgij (8.0 c.c.) ; 

Pepsini, £iss (6.0 gm.) ; 

Tincturse cardamomi composite, f^ss (15.0 c.c.) ; 

Aquae, q. s. ad fjiv (120.0 c.c). — M. 

Sig. A teaspoonful in water after meals. 

Incompatibles. — Hydrochloric acid is incompatible with 
oxids, alkalies, carbonates, and hydrates, with many metallic 
salts, with albumin, and with some glucosids (glycyrrhizin). 
In the above formula the hydrochloric acid sets free insoluble 
carminic acid, but its formation is of no moment. 

PEPSINUM, U. S. P. 

(Pepsin.) 

Pepsin is a proteolytic ferment obtained from the glandular 
layer of fresh stomachs from healthy pigs. To be up to the 
official standard, it should be capable of digesting, under 
favorable conditions, not less than 3000 times its own weight 
of freshly coagulated and disintegrated egg-albumen. It 
occurs as a yellowish-white, amorphous powder, or as yellow 
translucent scales, having a faint odor and slightly acidulous 
or saline taste. It is soluble in about 50 parts of water, more 



PA NCR EA TINUM. 1 8 3 

so in water containing hydrochloric acid, and insoluble in alco- 
hol. The dose is from 5-20 gr. (0.3-1.3 gm.). 

Therapeutics. — Pepsin is sometimes of service in chronic 
gastritis, atrophy of the gastric glands, and cancer, but, as a 
rule, it is less efficacious than pancreatin, and both are inferior 
to dilute hydrochloric acid and bitters. Care should be taken 
to secure a reliable preparation. Pepsin should be given in 
full doses, with hydrochloric acid, after meals. 

Most substances destroy or impair the proteolytic action 
of the drug, especially alcohol and alkalies. 

PANCREATINUM, U. S. P. 

(Pancreatin.) 

Pancreatin is a mixture of enzymes naturally existing in the 
pancreas of warm-blooded animals, and usually obtained from 
the fresh pancreas of the hog or ox. It appears as a yellow- 
ish-white, amorphous powder, having a faint odor and a meat- 
like taste. To be up to the official standard it should be 
capable of converting not less than 25 times its own weight of 
starch into substances soluble in water. The dose is from 5- 
20 gr. (0.3-1.3 gm.). 

In faintly alkaline solution pancreatin has the power of emul- 
sifying fats, and of converting proteids into diffusible peptones, 
and starches into sugars. In the presence of more than traces 
of mineral acids or large amounts of alkalies it soon becomes 
inert. 

Pancreatin is extensively used for peptonizing milk and 
other foods, the process being as follows : Mix 5 gr. (0.3 gm.) 
of pancreatin and 20 gr. (1.3 gm.) of sodium bicarbonate in a 
small teacupful of cool water, and pour into a bottle contain- 
ing a pint (0.5 L.) of fresh milk. Place the bottle in water so 
hot that the hand can be held in it without discomfort for a 
minute. As thoroughly digested milk has an unpleasant bitter 
taste, it is well to arrest digestion at the end of fifteen or 
twenty minutes by raising the milk for a few seconds to the 
boiling-point or by placing the bottle on ice. 

Pancreatin is a useful aid to digestion in conditions asso- 
ciated with hypoacidity. It should be combined with sodium 
bicarbonate and given immediately before or during meals, so 
that its digestive powers can be exercised in the stomach 
before the contents become distinctly acid. 

DIASTASE. 

Diastase is an amylolytic ferment obtained from malted 
grain — wheat, barley, oats, and rice. It ir. a yellowish-white 



1 84 CARMINA TI VES. 

or brownish-yellow amorphous powder, tasteless, soluble in 
water, but insoluble in alcohol ; I part, under favorable con- 
ditions, should convert 2000 parts of starch into dextrin and 
maltose. The dose is from 3-5 gr. (0.2-0.3 g m -)- 

Extracts of malt containing a variable quantity of diastase 
are extensively employed. They are marketed in 3 forms : 
A thin liquid closely resembling beer ; a thick brown, syrupy 
liquid, containing much saccharine material ; and a dry pow- 
der, containing, in addition to diastase, dextrin, dextrose, and 
the salts of barley. These extracts are used as digestants 
and as general tonics, but their value has been much overrated. 

Chittenden finds that although diastase will act in neutral 
or alkaline solutions, it is most effective in solutions that are 
slightly acid. It may be given before meals when there is 
difficulty in digesting starchy foods. 



PAPAYOTIN. 

(Papain ; Papoid ; Caroid.) 

Papayotin is an albuminous ferment obtained from Carica 
Papaya, true papaw, or melon tree, growing in the tropics. 
It is a grayish-white amorphous powder, tasteless, and without 
odor. It is quite soluble in water and glycerin, but insoluble 
in alcohol and ether. The dose is from 5-10 gr. (0.3-0.6 gm.). 

It is claimed for papayotin that it will convert proteids 
into peptone, starch into maltose, and emulsify fats ; and that, 
although it will act in neutral or acid solutions, it is most 
active in solutions of an alkaline reaction. Clinical experience 
with the preparations on the market indicates that the drug is 
of doubtful value. 



CARMINATIVES. 

Carminatives are drugs that aid in the expulsion of gas 
from the stomach or intestines. The origin of the word is 
somewhat obscure ; it is probably derived from carmen, a card 
for wool — that is, a cleanser, but according to some authori- 
ties it is derived from carmen, a charm. The gases found in 
the alimentary canal are swallowed with the food, are formed 
by the action of acid upon the carbonates contained in the 
saliva and food, or they are generated through fermentation 
or putrefaction of food. The most common cause, how- 
ever, of abnormal accumulation of gas is fermentation. 



CAPSICUM. 185 

Excessive accumulations of flatus distend the viscus, excite 
spasm of its muscular fibers, and thus occasion distress 
or actual pain. Carminatives prove effective probably by- 
relaxing the spasm, especially at the orifices, thus allowing 
the gas to escape. A form of distention occurs that is 
dependent upon atony of the walls of the stomach rather than 
upon an excessive accumulation of gas. In this condition 
carminatives are of little use. Although carminatives are 
chiefly valuable in expelling gas already formed, they also 
possess the power, to a very limited extent, of preventing the 
formation of flatus, for by quickening the gastric circulation and 
probably by increasing glandular activity, they play the part of 
stomachics, thus aiding digestion and lessening fermentation. 

As a class, carminatives are of service also in allaying spas- 
modic contraction of the intestine caused by irritants other 
than flatus ; thus they are effective in relieving colicky pains 
caused by irritant food or drugs, provided the irritation has 
not been sufficient to set up an inflammatory condition, in 
which case drugs of this class should be avoided. Carmina- 
tives are frequently combined with purgatives to prevent the 
griping pains that the latter are likely to induce when admin- 
istered alone. 

With the exception of alcohol, ether, and chloroform, carmi- 
natives are aromatics containing volatile oils as their chief active 
ingredients. The most important drugs of this class are : 

Capsicum. Ginger. Fennel. 

Pepper. Cinnamon. Coriander. 

Peppermint Cajuput. Asafetida. 

Spearmint. Anise. Ether. 

Cardamom. Pimenta. Compound 

Cloves. Sassafras. spirit of ether 

Nutmeg. Caraway. Chloroform. 

Turpentine. 

Carminatives are usually administered by the mouth, but 
asafetida and turpentine are often exceedingly efficacious in 
removing intestinal flatus when they are administered in the 
form of enemata. 



CAPSICUM, U. S. P. 

(Cayenne Pepper; African Pepper.) 

Capsicum is the fruit of Capsicum fastigiatum, a small shrub 
growing in tropical America, in Asia, and in Africa. Its active 
principle is probably capsaicin, which appears in the form of 



1 86 CARMINA TIVES. 

colorless crystals of an exceedingly pungent character. The 
dose of the powdered drug is from 1-3 gr. (0.06-0.2 gm.). 

Preparations. Dose. 

Tinctura Capsici, U. S. P 10-20 min. (0.6-1.2 c.c.) 

Fluidextractum Capsici, U. S. P I- 2 min. (0.06-0. 1 2 c.c). 

Oleoresina Capsici, U. S. P \- I min. (0.016-0.06 c.c). 

Pilulae Podophylli, Belladonnse et Capsici, U. S. P. I- 2 pills. 
Emplastrum Capsici, U. S. P. 

Physiologic Action and Therapeutics. — Externally 
applied, capsicum excites burning and redness, and in concen- 
trated form even vesication. When taken internally in small 
doses, it produces a sense of warmth in the stomach, stimu- 
lates peristalsis, and aids in the expulsion of flatus. Large 
doses produce severe irritation of the gastro-intestinal and the 
genito-urinary tract, characterized by pain, vomiting, purging, 
and dysuria, with scanty, dark-colored urine. It is employed 
chiefly as a rubefacient, stomachic, and carminative. In the 
form of a liniment it is sometimes an excellent remedy in wry- 
neck, muscular rheumatism, and sprains. Capsicum plaster 
is an efficient counterirritant in pleurodynia and bronchitis. 
Combined with cantharides (tincture of cantharides, tincture 
of capsicum, and alcohol, of each, \ fl. oz. — 15 c.c.) it is fre- 
quently employed as a stimulating lotion in alopecia areata. A 
gargle consisting of half an ounce (15 c.c.) of the tincture in 
half a pint (235 c.c.) of water has been much used in domestic 
medicine in sore throat with relaxation of the uvula, but the 
remedy is inferior to many others, and in severe inflammations 
it is calculated to do harm. 

In the gastric catarrh following an alcoholic debauch, and 
characterized by fetid breath, a heavily furred tongue, ano- 
rexia, nausea, and a sinking sensation in the epigastrium, the 
tincture of capsicum in ten-drop doses is an invaluable sto- 
machic. In the flatulent dyspepsia of the aged, especially of old 
gourmands, it is a useful adjuvant to other stomachics. Cay- 
enne pepper in small doses may be employed to promote the 
absorption of certain drugs, notably of quinin. In obstinate 
constipation due to deficient peristalsis a small amount of the 
oleoresin may be added advantageously to a cathartic pill. 



PIPER, U. S. P. 

(Black Pepper.) 

Black pepper is the unripe fruit of Piper nigrum, a climbing 
vine cultivated in the East Indies. It contains a crystalline 



MENTHA PIPERITA— MENTHA VIRIDIS. 1 8? 

neutral principle, piperin, an aromatic volatile oil, and a pun- 
gent resin. 

Preparations. Dose. 

Piperina, U. S. P. 1-5 gr. (0.06-0.3 gm.). 

Oleoresina Piperis, U. S. P £-2 min. (0.03-0.1 c.c). 

Therapeutics. — Pepper is used chiefly as a condiment. 
Owing to its carminative properties, the oleoresin is sometimes 
added to cathartic pills. Piperin was at one time considered 
to be of value in malarial fever, but for lack of satisfactory- 
evidence of its efficacy its use in this affection has been entirely 
abandoned. 



MENTHA PIPERITA, U. S. P. 

(Peppermint.) 

Peppermint is the leaves and tops of Mentha piperita, a 
perennial herb growing in wet places throughout the Temper- 
ate Zone. Its active principle is a greenish-yellow volatile 
oil, having a strong, characteristic odor and a pungent taste, 
followed by a sense of coolness when air is drawn into the 
mouth. When subjected to refrigeration, it yields the stear- 
opten, menthol (p. 157). 

Preparations. Dose. 

Oleum Menthae Piperitae, U. S. P 1-5 min. (0.06-0.3 c.c). 

Spiritus Menthae Piperitae, U. S. P. (10 per cent.) 10-30 min. (0.6-2.0 c.c). 
Aqua Menthae Piperitae, U. S. P 1-4 fl. dr. (4.0-15.0 c.c). 

The oil also enters into the official compound pills of rhu- 
barb and vegetable cathartic pills. 

Therapeutics. — Peppermint has long been employed as 
a carminative for relieving flatulence and colic, especially in 
young children. It is particularly useful in covering the taste 
of unpalatable medicines. The oil, or better still menthol, is 
sometimes effective, when applied locally, in relieving the 
milder forms of neuralgia. 

MENTHA VIRIDIS, U. S. P. 

(Spearmint.) 

Spearmint is the leaves and tops of Mentha spicata, a peren- 
nial herb growing wild in Europe and North America. Its 
active principle is a volatile oil. 



1 88 CARMINA TIVES. 

Preparations. Dose. 

Oleum Menthae Viridis, U. S. P 1-5 min. (0.06-0.3 c.c). 

Spiritus Menthae Viridis, U. S. P. (10 per cent.) 10-30 min. (0.6-2.0 c.c). 
Aqua Menthae Viridis, U. S. P 1-4 fl. dr. (4.0-15.0 c.c). 

Spearmint is the therapeutic equivalent of peppermint 
CARDAMOMUM, U. S. P. 

(Cardamom.) 

Cardamom is the fruit of Elettaria repens, a perennial herb 
cultivated in the mountainous regions of India. Its active 
principle is a volatile oil, of which it contains about 5 per 
cent. 

Preparations. Dose. 

Tinctura Cardamomi, U. S. P 1-2 fl. dr. (4.0-8.0 c.c). 

Tinctura Cardamomi Composita, U. S. P. (con- 
tains also cinnamon, caraway, cochineal, 

and glycerin) 1-2 fl. dr. (4.0-8.0 c.c). 

Pulvis Aromaticus, U. S. P. (contains also 

ginger, cinnamon, and nutmeg) 10-30 gr. (0.6-2.0 gm.). 

Cardamom also enters into the compound extract of colo- 
cynth, compound tincture of gentian, tincture of rhubarb, and 
aromatic tincture of rhubarb. 

Therapeutics. — It is used as an agreeable aromatic for 
disguising the taste of other drugs, and as an adjuvant to simple 
bitters in flatulent dyspepsia. When free acids are added to 
the compound tincture of cardamom, they separate from the 
cochineal insoluble carminic acid, but this incompatibility is of 
no particular importance. 

CARYOPHYLLUS, U. S. P. 

(Cloves.) 

Cloves are the unexpanded flowers of Eugenia aromatica, 
an evergreen indigenous to the East Indian Islands, and culti- 
vated to some extent in South America and Africa. They 
contain a yellow volatile oil of a characteristic odor and a 
pungent, spicy taste. The chief constituent of the oil is 
Eugenol. 

Preparations. Dose.. 

Oleum Caryophy Hi, U. S. P I -5 min. (0.06-0.3 c.c). 

Eugenol, U. S. P 1-5 min. (0.06-0.3 c.c). 

They also enter into compound tincture of lavender, aro- 
matic tincture of rhubarb, and wine of opium. 

Therapeutics. — Cloves are used as a counterirritant, local 
anesthetic, and carminative. They are one of the active ingre- 



MYR IS TIC A— ZINGIBER. 1 89 

dients of the spice-poultice, which consists of powdered cloves, 
ginger, and cinnamon, of each, one or two teaspoonfuls ; flour, 
a tablespoonful ; whisky, sufficient to make a mass moist 
enough to spread on soft flannel. In this form they are a 
useful rubefacient for applying to the abdomen of children 
suffering from diarrhea. As a carminative, the oil is a useful 
addition to laxative pills, aiding materially in preventing 
griping. In intestinal colic brought on by exposure a drop or 
two of the oil in a teaspoonful of paregoric, repeated at short 
intervals, often gives speedy relief. The oil is also a popular 
remedy for toothache, being applied on a pledget of cotton to 
the cavity of the tooth. 

MYRISTICA, U. S. P. 

(Nutmeg.) 

Nutmeg is the seed of Myristica fragrans, an evergreen tree 
growing in the Molucca Islands and neighboring East India 
Islands. It contains a volatile oil, upon which its aromatic 
properties depend, and a fixed oil. 

Preparation. Dose. 

Oleum Myristicse, U. S P 1-5 min. (0.06-0.3 c.c). 

Nutmeg also enters into aromatic powder, compound tinc- 
ture of lavender, aromatic tincture of rhubarb, aromatic spirit 
of ammonia, and troches of sodium bicarbonate. 

In large doses nutmeg acts as a narcotic poison, producing 
headache, vertigo, delirium, stupor, coma, and, finally, death 
from respiratory paralysis. Like cloves, it is employed as a 
carminative and a local anodyne. 

ZINGIBER, U. S. P. 

(Ginger.) 

The rhizome of Zingiber officinale, a perennial herb growing 
in tropical countries. It contains a volatile oil having the odor 
of ginger, and a viscid resinous principle having a hot, pungent 
taste. 

Preparations. Dose. 

Tinctura Zingiberis. U. S. P 20-60 min. (1.2-4.0 c.c). 

Fluidextractum Zingiberis, U. S. P. . . 10-30 min. (0.6-2.0 c.c.). 

Syrupus Zingiberis, U. S. P £-4 fl. dr. (2.0-15.0 c.c). 

Oleoresina Zingiberis, U. S. P ^-2 min. (0.03-0.1 c.c). 

Ginger also enters into compound powder of rhubarb and 
aromatic powder. 

Therapeutics. — It is employed as a carminative and as a 
flavoring agent. 



1 90 CARMINA TIVES. 

CINNAMOMUM. 

(Cinnamon.) 

The United States Pharmacopoeia recognizes 2 varieties of 
cinnamon : Cinnamomum Saigonicum (Saigon cinnamon), a 
species cultivated in the neighborhood of Saigon, the capital of 
French Cochin-China, and Cinnamomum Zeylanicum (Ceylon 
cinnamon). Cinnamon contains a volatile oil and a small 
amount of tannin. The oil consists chiefly of cinnamic aide- 
kyd, which on exposure is oxidized into resin and cinnamic 
acid. The official oil is distilled from Cassia or Chinese cin- 
namon. 

Preparations. Dose. 

Oleum Cinnamomi, U. S. P 1-5 min. (0.06-0.3 c.c). 

Cinnaldehydum, U. S. P £-3 min. (0.03-0.2 c.c.). 

Spiritus Cinnamomi, U. S. P. (10 percent. 

of oil) 10-30 min. (0.6-2.0 c.c). 

Tinctura Cinnamomi, U. S. P. (10 per cent. 

of cinnamon) \~2. fl. dr. (2.0-8.0 c.c). 

Aqua Cinnamomi, U. S. P \-\ fl. oz. (15.0-30.0 c.c). 

Cinnamon also enters into aromatic fluidextract, infusion of 
digitalis, compound tincture of cardamom, compound tincture 
of lavender, compound tincture of gambir, wine of opium, and 
aromatic powder. 

Therapeutics. — Cinnamon possesses carminative and 
feebly astringent properties. The oil is an active antiseptic. 
Cinnamon- water is an agreeable vehicle for diarrhea mixtures. 
The oil has been used to some extent as an antiseptic in surgi- 
cal dressings. Very favorable results have been reported from 
the use of cinnamon in influenza. 

Cinnamic acid and its sodium salt have been highly extolled 
by Landerer, Heusser, and others in the treatment of tubercu- 
losis. It is claimed that intravenous injections of sodium cin- 
namate (\ gr. — 0.008 gm. — every forty-eight hours, gradually 
increased to \ gr. — 0.02 gm.) induce a marked hyperleukocy- 
tosis and favor the formation of cicatricial tissue around the 
tuberculous area. A careful review of the reported cases, 
however, does not warrant the belief that this method of treat- 
ment is any more effective than other methods that are far less 
painful. 

OLEUM CAJUPUTI, U. S. P. 

(Oil of Cajuput.) 

Oil of cajuput is a thin, bluish-green, volatile oil distilled 
from the leaves of Melaleuca Leucadendron, a small tree grow- 
ing in the East India Islands. It has a camphoraceous odor 



ANISUM— SASSAFRAS. I9I 

and an aromatic, bitter taste. The dose is from 2-10 min. 
(0.12-0.6 c.c.) in emulsion, in capsules, or on sugar. 

Therapeutics.— Cajuput oil is one of the most efficient of 
the carminatives. It is an excellent adjunct to other remedies 
in the flatulent dyspepsia of the aged. Combined with opium 
it is undoubtedly useful in diarrhea with choleraic symptoms. 
It has been used also as a rubefacient in muscular rheumatism 
and as a parasiticide in ringworm. 

ANISUM, U. S. P. 

(Anise.) 

Anise is the fruit of Pimpinella Anisum, a small plant culti- 
vated in Southern Europe and North America. It contains 
a volatile oil having the characteristic odor of anise and a 
sweetish, aromatic taste. 

Preparations. Dose. 

Oleum Anisi, U. S. P 2-5 min. (0.12-0.3 c.c). 

Aqua Anisi, U. S. P 2-8 fl. dr. (8.0-30.0 c.c). 

Spiritus Anisi, U. S. P. (10 per cent, of oil) . 1-2 fl. dr. (4.0-8.0 c.c). 

Anise also enters into camphorated tincture of opium, com- 
pound spirit of orange, aromatic elixir, compound syrup of 
sarsaparilla, and troches of opium and licorice. 

Therapeutics. — Although anise is an effective carminative, 
it is used chiefly as a flavoring agent. 

PIMENTA, U. S. P. 

(Allspice.) 

Allspice is the nearly ripe fruit of Pimenta officinalis, an 
evergreen tree growing in the West Indies and South America. 
It contains a volatile oil, the active constituent of which is 
Eugenol. 

Preparation. Dose. 

Oleum Pimentae, U. S. P 1-5 min. (0.06-0.3 c.c). 

Oil of pimenta enters into spirit of myrcia, or bay-rum. 



SASSAFRAS. 

Sassafras is official as the bark {sassafras) and as the pith 
(sassafras medulla) of Sassafras variifolium, a shrub or tree 
growing in Eastern North America. It contains a fragrant, 
aromatic, volatile oil and a fair amount of tannin (6 per cent). 



192 CARMINATIVES. 

Preparations. Dose. 

Oleum Sassafras, U. S. P 1-5 min. (0.06-0.3 c.c). 

Mucilago Sassafras Medulbe, U. S. P. (2 per 

cent.) 1-8 fl. dr. (4.0-30.0 c.c). 

Sassafras also enters into compound fluid extract of sarsapa- 
rilla, compound syrup of sarsaparilla, and troches of cubeb. 



CARUM, U. S. P. 

(Caraway.) 

Caraway is the fruit of Carum Carvi, an herb indigenous to 
Asia, and cultivated in Europe and North America. Its 
active ingredient is a volatile oil. 

Preparation. Dose. 

Oleum Cari, U. S. P 1-5 min. (0.06-0.3 c.c). 

Caraway also enters into compound tincture of cardamom 
and compound spirit of juniper. 

FCENICULUM, U. S. P. 

(Fennel.) 

Fennel is the fruit of Fceniculum vulgare, grown chiefly in 
Southern Europe. It contains an aromatic volatile oil. 

Preparations, Dose. 

Oleum Foeniculi, U. S. P 1-5 min. (0.06-0.3 c.c). 

Aqua Foeniculi, U. S. P 1-8 fl. dr. (4.0-30.0 c.c). 

Fennel also enters into compound licorice powder, com- 
pound spirit of juniper, and compound infusion of senna. 

CORIANDRUM, U. S. P. 

( Coriander. ) 

Coriander is the fruit of Coriandrum sativum, an herb grown 
in all parts of Europe and the United States. It contains a 
volatile oil. 

Preparation. Dose. 

Oleum Coriandri, U. S. P 1-5 min. (0.06-0.3 c.c). 

Coriander also enters into confection of senna, syrup of 
senna, and compound spirit of orange. 



CATHARTICS. 1 93 

The carminative properties of asafetida, ether, compound 
spirit of ether y chloroform, and turpentine are discussed else- 
where in this volume. 



CATHARTICS. 



Cathartics are drugs that are employed in medicine to cause 
evacuation of the bowels. They may act by irritating the in- 
testines or by augmenting the fluid of the feces. In the first in- 
stance intestinal peristalsis is increased directly, and in the second 
instance it is increased indirectly by distention of the bowel. 
Vegetable cathartics (castor oil, rhubarb, aloes, jalap, podo- 
phyllum, etc.), calomel, and phenolphthalein act through their 
irritant properties. These drugs also render the stools more 
or less watery ; but this effect is to be ascribed to the rapid 
evacuation of the intestinal contents and the escape of much 
liquid that would otherwise be reabsorbed, or, in case the 
action of the drug has been more or less violent, to the devel- 
opment of a true inflammatory process with serous exudation. 

Saline cathartics do not irritate the bowel unless given in 
very large doses. On the other hand, they retard the absorp- 
tion of liquids (if in isotonic or hypotonic solution) and with- 
draw water from the blood (if in hypertonic solution), and thus, 
by distending the bowel, stimulate peristaltic movements. 
Only salts that are difficult of absorption, like the sulphates, 
phosphates, and tartrates, have a purgative effect. Magnesium 
sulphate is especially active in this respect, as neither its basic 
nor its acid ion is readily absorbed. Nitrates, chlorides, ace- 
tates, and other rapidly absorbed salts induce diuresis rather than 
purgation because they draw water from the tissues into the 
blood, and so increase the capillary pressure in the kidneys. 

It has long been accepted as a fact that certain cathartics, like 
mercury and sodium phosphate, stimulate the liver and increase 
the secretion of bile, and, in consequence, these drugs have been 
known as cholagogues or cholagogue purgatives. Not much 
evidence, however, can be adduced in support of this assump- 
tion. It is true that the group of symptoms to which the term 
" biliousness " is applied often disappears as by magic after the 
administration of a full dose of calomel, but there is no proof 
that these symptoms are due to inactivity of the liver ; on the 
contrary, there is much to support the view that they are due 
solely to some derangement of the stomach and intestines. Nor 
can the dark green color of the stools that is observed after the 
administration of certain cathartics be claimed as an evidence 

13 



194 CATHARTICS. 

of increased secretion, for it is doubtless due, in large part, to 
the rapid flow of bile into the lower bowel and its escape 
from decomposition and reabsorption. Rutherford ligated the 
common bile-duct, inserted a cannula into it, and then noted 
the effect that the injection of certain drugs into the duod- 
enum had upon the flow of bile. From his experiments he 
concluded that the following drugs increase the secretion of 
bile: 

Podophyllin. Jalap. 

Aloes. Sodium sulphate. 

Rhubarb. Sodium phosphate. 

Colchicum. Rochelle salt. 

Iridin. Euonymin. 

Colocynth. Ipecacuanha. 

Corrosive sublimate. 

Unfortunately, Rutherford's experiments were too few in 
number and his results too often contradictory to justify his 
conclusions, and, moreover, recent investigations, especially 
those of Stadelmann and Pfafif,, have failed completely to con- 
firm the facts embodied in Rutherford's report. The only 
body known to have a decided cholagogue action is bile itself, 
although salicylic acid and its salts also promote the biliary 
secretion to a slight extent. 

The colicky pains induced by cathartics are probably the 
result of scybala interrupting the regular peristaltic move- 
ments, and throwing the muscular fibers into violent spasm. 
This view is confirmed by the experiments of Cash, who found 
that the slightest weight sufficed to check the onward move- 
ment of the substance in the intestine and to set up contrac- 
tions of a painful character. 

Classification. — Cathartics have been variously classified 
according to the intensity of their action and the character of 
the stools they produce. Since the effect of any cathartic is 
dependent, to a great extent, upon the dose, the time of ad- 
ministration, the susceptibility of the patient, and the state of 
the bowel, it is evident that a classification based upon physi- 
ologic action must necessarily be an imperfect one ; neverthe- 
less, when its limitations are fully recognized, such a classifi- 
cation is the most convenient one that can be adopted. 
Cathartics, therefore, may be divided into laxatives, purgatives, 
drastics, and hydragogues. 

Laxatives are the least irritating of all the cathartics, and 
ordinarily produce stools that are nearly normal in appearance 
and consistence. Many articles of food, such as molasses, 



INDICA TIONS. 195 

bran bread, figs, prunes, apples, etc., serve as laxatives. The 
most important drugs belonging to this class are : 

Manna. Cassia fistula. 

Tamarind. Euonymus. 

Cascara sagrada. Butternut. 

Frangula. Iris. 

Magnesia. Leptandra. 

Sulphur. Ox-gall. 

Purgatives are more powerful than laxatives, and usually 
produce one or more copious stools of a semiliquid consist- 
ence. The difference between the action of a laxative and 
that of a purgative is mainly one of degree : laxatives in large 
doses act as purgatives, and the latter in small doses act as 
laxatives. The most important purgatives are : 

Aloes. Castor oil. 

Rhubarb. Calomel. 

Senna. Blue mass. 

Drastics have a violent action, and in overdoses produce 
the symptoms of acute enteritis. The most important are : 

Croton oil. Podophyllum. 

Colocynth. Jalap. 

Gamboge. Elaterium. 

Scammony. Bryonia. 

Hydrag-ogues produce large watery stools and give rise to 
but slight irritation. The principal ones are : 

Magnesium sulphate. Potassium and sodium tartrate. 

Sodium sulphate. Sodium phosphate. 

Magnesium citrate. 

Some of the drastics, especially jalap, elaterium, and bryo- 
nia, in appropriate doses, are efficient hydragogues. 

Indications. — To Relieve Constipation. — In simple acute 
constipation the prompt administration of a cathartic or the 
employment of an enema is nearly always advisable. In 
chronic constipation the result of atony of the bowel a resort 
should first be had to dietetic and hygienic measures, but, 
these failinc, a laxative should be prescribed. As a rule, the 



I96 CATHARTICS. 

use of laxatives in these cases, even when habitual, is less 
baneful than the persistent constipation. Indeed, mild vege- 
table cathartics are often taken for indefinite periods without 
producing, harmful effects. Brodie speaks of a man, eighty- 
six years of age, who for threescore years took an aloetic pill 
every night. 

To Remove Irritants from the Bowel. — In the beginning of 
acute diarrhea it is generally well to administer a dose of 
castor oil, calomel, or Epsom salts, to rid the bowel of undi- 
gested material, ptomains, and micro-organisms. In poisoning, 
if the irritant has escaped from the stomach into the bowel, a 
purgative should take the place of an emetic. 

To Promote Absorption. — Hydragogue cathartics, especially 
the salines, are often useful in cardiac and renal dropsy. They 
not only remove directly from the body a certain amount of 
fluid, but, by depleting the blood, promote the reabsorption of 
the lymph that has accumulated in the tissues. 

In serous effusions of an inflammatory character, such as are 
met with in pleurisy and pericarditis, cathartics are rarely 
serviceable. 

Certain drugs, such as digitalis and quinin, may prove inef- 
fective until the bowel has been unloaded and the portal 
system depleted by the administration of a brisk cathartic. 

To Remove Excrementitious Substances from the Blood. — In 
uremia and puerperal eclampsia the administration of cathartics 
is a measure of the greatest value in securing the elimination 
of noxious material. 

To Relieve Cerebral Congestion. — In acute cerebral congestion 
and mania cathartics serve a useful purpose, since, by 
inviting blood to the bowel, they tend to deplete the brain. 
In cerebral hemorrhage, also, they may do good by prevent- 
ing further extravasation. 

Administration. — Cathartics are most commonly admin- 
istered by the mouth. The salines are given in solution ; the 
vegetable preparations, most conveniently in the form of pills. 
In chronic constipation a combination of several drugs usually 
gives rise to less pain and is more effective than a single drug. 
A little of the extract of belladonna or a drop of one of the 
aromatic oils is frequently employed as an adjuvant to prevent 
griping. When atony of the bowel is pronounced, extract of 
nux vomica or physostigma may be added to the pill to 
enhance its stimulating effect. The time of administration is 
a factor to be considered in prescribing any cathartic. Pills 
of the vegetable cathartics are likely to cause less inconve- 
nience if administered after the evening meal or on going to 



ADMINISTRA TION. 1 97 

bed. Salines or saline mineral waters act more promptly and 
powerfully when given before breakfast. 

Very often an enema is the most satisfactory means of 
unloading the bowel. A metal syringe with a piston or one 
made entirely of soft rubber may be employed for the purpose. 
The syringe should be filled with the fluid ; all the air should 
be expelled from it before the nozzle is inserted. The patient 
should lie near the edge of the bed, on the left side, with the 
knees drawn up. A towel should be held against the anus 
on withdrawing the nozzle, so that the fluid may be retained 
in the bowel for several minutes. An enema may act by dis- 
tending the bowel (mechanically), by softening the intestinal 
contents, or by directly irritating the intestinal walls. 

A simple enema is one composed of cool or tepid water or 
of soap and water. For an infant, 1 or 2 ounces (30.0-60.0 c.c.) 
may be employed ; for a child, from 4 to 8 ounces ( 1 20.0-240.0 
c.c.) ; and for an adult, from 1 to 2 pints (0.5-1.0 L.). The injec- 
tion may be made more powerful by adding, in the case of an 
adult, 1 ounce (30.0 c.c.) of castor oil, J ounce (15.0 c.c.) of 
molasses, or from 1 to 2 drams (4.0-8.0 c.c.) of turpentine. 
The following enema, official in the British Pharmacopeia, is 
very useful : 

Magnesium sulphate I ounce (30.0 c.c.). 

Olive oil 1 ounce (30.0 c.c). 

Mucilage of starch 15 ounces (445.0 c.c). 

A small enema of glycerin (1-2 drams — 4.0-8.0 c.c.) is gen- 
erally very efficacious. In cases of fecal impaction an enema 
of warm salad or linseed oil (6-8 ounces — 180.0-240.0 c.c.) 
or an infusion of ox-gall often proves serviceable. In some 
cases of chronic indigestion with constipation flushing out the 
lower bowel with from 6 to 8 pints (3.0-4.0 L.) of tepid water, 
two or three times a week, by means of a soft-rubber tube 
passed well up into the sigmoid flexure, is followed by excel- 
lent results. 

It is well to remember that bulky enemata containing hard 
soap are occasionally followed, after the lapse of a few hours, 
by a scarlatiniform, measly, or urticarial rash. 

The introduction into the rectum of suppositories made of 
yellow soap, glycerin, or gluten is another means frequently 
employed to unload the bowel. 

It has been shown that certain drugs — aloin, colocynthin, 
and cathartic acid — will produce catharsis when given hypo- 
dermically. The irritation caused by the injections of these 
substances, however, is so severe as to forbid the employ- 
ment of this method of administration except under unusual 
circumstances. 



198 CATHARTICS. 

MANNA, U. S. P. 

Manna is a concrete saccharine exudation from Fraxinus 
Ornus, a small tree a native of Sicily and other Mediterranean 
islands. It occurs in the form of yellowish-white or brownish- 
white three-edged pieces or fragments, having a crystalline 
structure, a honey-like odor, and a sweetish, faintly acrid 
taste. Its chief constituent is mannite (50-80 per cent.), a 
sweet crystalline principle soluble in water. In doses of from 
I to 2 ounces (15.0-60.0 gm.) manna acts as a mild laxative. 
It is usually given in combination with other cathartics. 

Preparation. Dose. 

Infusum Sennse Compositum, U. S. P. (Black 

Draft) 1-4 fl. oz. (30.0-120.0 c.c). 

TAMARINDUS, U. S. P. 

(Tamarind.) 

Tamarind is the preserved pulp of the fruit of Tamarindus 
indica, a large tree indigenous to Africa, and cultivated in 
the West Indies. It is a gentle laxative, about equal in power 
to the fig and prune. Its aperient properties are due chiefly 
to the potassium salts of tartaric, citric, malic, and acetic acids, 
of which it contains from 8 to 12 per cent. The dose is from 
I to 8 drams (4.0-30.0 gm.). 

Preparation. Dose. 

Confectio Sennae, U. S. P 1-2 dr. (4.0-8.0 gm.). 

RHAMNUS PURSHIANA, U. S. P. 

(Cascara Sagrada; Chittem Bark.) 

Cascara sagrada is the bark of Rhaimius Purshiana, a small 
tree growing in Northern California, Oregon, and Washington. 
It is allied to Rhamnus Frangula (buckthorn) and to Rham- 
nus cathartica (buckthorn). It contains emodin and other 
anthracene derivatives, 1 and so is allied chemically to frangula, 
rhubarb, aloes, and senna. 

Preparations. Dose. 

Fluidextractum Rhamni Purshianae, U. S. P. . 10-30 min. (0.6-2.0 c.c). 
Fluidextractum Rhamni Purshianse Aromati- 

cum,U. S. P IO-30 min. (0.6-2.0 c.c). 

Extractum Rhamni Purshianse, U. S. P. . . . 2-8 gr. ( 1. 3-0.5 gm.). 

1 These bodies are substitution products of anthraquinone. Among them are 
emodin, cathartin, frangulin, aloin, and chrysophanic acid. Recently three syn- 
thetic anthracene compounds have been put upon the market as substitutes for 
the crude drugs : purgatin, exodin, and purgen (phenolphthalein). 



FRANGULA—MAGNESII OXIDUM. 1 99 

Therapeutics. — Cascara sagrada is used exclusively as a 
tonic laxative, and in habitual constipation due to torpor of the 
bowel it is a most reliable remedy. It possesses a great 
advantage over many cathartics in not readily losing its effect 
when frequently taken ; indeed, in many cases the dose can 
be diminished gradually and still give satisfactory results. 

In most cases a single dose at bedtime will afford relief, but 
sometimes small doses (10 drops) after each meal are more 
effective. On account of its unpleasant bitter taste the fluid 
extract is best given in some aromatic syrup or cordial, as in 
the following formula : 

R Fluidextracti rhamni purshianae, 

Fluidextracti sarsaparillae compositi. 

Glycerini, aa f^j (30.0 c.c). — M. 

Dose : A teaspoonful or more. 

FRANGULA, U. S. P. 

(Buckthorn.) 

Frangula is the bark of Rhamnus Frangula, a shrub grow- 
ing in Europe and Northern Asia. When fresh, it is a power- 
ful irritant, but its action is modified by age, and therefore the 
Pharmacopeia specifies that it should be at least one year old 
before being used. It contains a crystalline glucosid, fran- 
gulin. 

Preparation. Dose. 

Fluidextractum Frangulae, U. S. P \-\ fl. dr. (2.0-4.0 c.c.y 

Frangula has an action not unlike that of senna. In this ¥ 
country it has been almost entirely displaced by Rhamnus 
Purshiana. 

MAGNESII OXIDUM, U. S. P. 

(Light Magnesia; Calcined Magnesia; Magnesium Oxid ; MgO.) 

Light magnesia is a white, very light, odorless powder, 
having an earthy taste. It is almost insoluble in water, insolu- 
ble in alcohol, but soluble in dilute acids. The dose as a 
laxative is from 30-60 gr. (2.0-4.0 gm.). 

Preparations. Dose. 

Pulvis Rhei Compositus, U. S. P. (6$ per 

cent.) 30-60 gr. (2.0-4.0 gm.). 

Ferri Hydroxidum cum Magnesii Oxido, 

U. S. P 2-4 fl. oz. (60.0-120.0 c.c). 

Therapeutics. — Magnesia is partly converted by the 
acids of the stomach into soluble salts that have a laxative 



200 CA THA R TICS. 

action ; it therefore combines the properties of an antacid with 
those of a mild aperient. It is not a suitable drug for habitual 
use in simple chronic constipation, since, when not thoroughly- 
acidified, there is a possibility of its forming intestinal concre- 
tions. It may replace sodium bicarbonate, however, when ex- 
cessive acidity exists with constipation. In ulcer of the stomach 
it may be combined with bismuth subnitrate to control con- 
stipation. It may be given with syrup of rhubarb in the early 
stages of acute diarrhea to rid the bowel of any sour, acrid 
material that may give rise to irritation. It is also an antidote 
in arsenic poisoning, and is doubly efficient in the form of 
ferric hydrate with magnesia. 

MAGNESII OXIDUM PONDEROSUM, U. S. P. 

(Heavy Magnesia ; Heavy Calcined Magnesia ; Magnesium Oxid; MgO.) 

Heavy magnesia is three and a half times heavier than light 
magnesia, and, unlike the latter, does not readily unite with 
water to form a gelatinous hydrate. It has the same proper- 
ties and uses as light magnesia. 

MAGNESII CARBONAS, U. S. P. 

(Magnesium Carbonate; (MgC0 3 ) 4 .Mg(OH) 2 +5H 2 0.) 

Magnesium carbonate occurs in light, white, friable masses 
or as a light white powder, free from odor, and having a 
slightly earthy taste. It is almost insoluble in water, insolu- 
ble in alcohol, but soluble in dilute acids with active efferves- 
cence. The dose as a laxative is from 20-60 gr. (1.3-4.0 gm.). 

Magnesium carbonate has the same therapeutic value as 
magnesia, but when there is much acid in the stomach, it is 
likely to cause unpleasant eructations of gas. 

SULPHUR. 

(S.) 

The United States Pharmacopeia recognizes 3 forms of 
sulphur : 

Sulphur Sublimatum. 
Sulphur Lotum. 
Sulphur Praecipitatum. 

Sublimed sulphur (flowers of sulphur) is a fine yellow 
powder having a slightly characteristic odor and a faintly 
acid taste. It is insoluble in water, but partially soluble in 
absolute alcohol, ether, chloroform, boiling solutions of alka- 



CASSIA FISTULA. 201 

line hydrates, oil of turpentine, and many other oils. It 
usually contains small quantities of sulphuric acid, arsenic 
sulphid, and other impurities. The dose is from 10 to 120 
gr. (0.65-8.0 gm.). 

Washed sulphur is prepared by digesting for three days 
sublimed sulphur in weak ammonia water. 

There are 2 official preparations of washed sulphur : 

Unguentum Sulphuris (15 per cent). 

Pulvis Glycyrrhizae Compositus (8 per cent.). 

Precipitated sulphur (milk of sulphur) is a fine, almost 
white powder, without odor or taste. It is prepared by pre- 
cipitating calcium sulphid with diluted hydrochloric acid. 
The dose is from 10 to 120 gr. (0.65-8.0 gm.). 

Physiologic Action and Therapeutics. — When sul- 
phur is taken internally, a considerable portion passes out 
unchanged ; some, however, is converted by the alkaline secre- 
tions of the bowel into hydrogen sulphid and other sulphids. 
It is to the latter compounds that sulphur owes its active prop- 
erties. They are the cause of the mild catharsis and the offen- 
sive flatus that follow the ingestion of sulphur. Being partially 
absorbed, they escape from the lungs and skin as sulphids, 
and from the kidneys as sulphates. 

Sulphur may be employed as a laxative when a very mild 
action is desirable, as in pregnancy, hemorrhoids, fissure of the 
anus, and prolapse of the bowel. The dose as a laxative is 
from I to 2 dr. (4.0-8.0 gm.) in syrup or molasses. Sulphur 
has a long-standing reputation, both as an internal remedy 
and as a local application, in chronic articular rheumatism. 
Externally, it is much used as a stimulant and parasiticide in 
certain chronic diseases of the skin. It is often useful in 
eczema, comedo, acne, and psoriasis, and it may be prescribed 
in an ointment having the strength of from \ to 2 dr. (2.0-8.0 
gm.) to the ounce (30.0 gm.). It is absolutely contraindicated 
in the acute stages of any skin disease. In parasitic diseases, 
like scabies and ringworm, it is a reliable remedy. 

CASSIA FISTULA, U. S. P. 

(Purging Cassia.) 

Purging cassia is the fruit of Cassia Fistula, a tree exten- 
sively cultivated in all tropical countries. It contains about 
60 per cent, of sugar, with albuminoids and organic salts. The 
dose is from 1-4 dr. (4.0-15.0 gm.). It has a mild laxative 



202 CATHARTICS. 

action, but on account of its tendency to cause griping, it is 
prescribed only in combination with other remedies. 

Preparation. Dose. 

Confectio Sennae, U. S. P. (16 per cent.) . . 1-2 dr. (4.0-8.0 gm.). 

EUONYMUS, U. S. P. 

(Wahoo.) 

Euonymus is the bark of the root of Euo?iymus atropur- 
pureiis, growing in Eastern North America. It contains a 
soluble, amorphous glucosid, euonymin, which affects the cir- 
culation like digitalis. The dose of the latter is from |— 3 gr. 
(0.03-0.2 gm.). 

Preparations. Dose. 

Extractum Euonymi, U. S. P 1-5 gr. (0.065-0.3 gm.). 

Fluidextractum Euonymi, U. S. P 5-20 min. (0.3-1.3 c.c). 

The cathartic action of euonymus resembles that of podo- 
phyllum, although it is less powerful. It has been credited 
with cholagogue as well as laxative properties, but although 
it undoubtedly hastens the elimination of bile and prevents the 
reabsorption of that secretion, there is not sufficient proof to 
warrant the belief that the drug actually increases the func- 
tional activity of the liver. 

Combined with other cathartics, euonymus is a useful remedy 
in the condition popularly known as " biliousness." 

JUGLANS. 

(Butternut.) 

Butternut is the bark of the root of Juglans cinerea, a large 
tree belonging to the walnut family, and growing in North 
America. 

Preparation. Dose. 

Extractum Juglandis 5~io gr. (0.3-0.65 gm.). 

Its action somewhat resembles that of rhubarb, for which it 
has been used as a substitute. It is seldom employed at the 
present day. 

IRIS. 

(Blue Flag.) 

Blue flag is the rhizome and roots of Iris versicolor, a peren- 
nial herb growing in the swampy places of North America. 
It contains an acrid resin and possibly an amorphous alkaloid. 



LEPTANDRA—FEL BO VIS. 203 

Preparations. Dose. 

Fluidextractum Iridis 10-20 min. (0.6-1.3 c.c). 

Extractum Iridis 1-4 gr. (0.06-0.25 gm.). 

Iris in sufficient dose produces active catharsis with bilious 
stools. Its action resembles that of podophyllum, though 
milder. At one time held in high esteem, it has at present 
fallen into disuse. 

LEPTANDRA, U. S. P. 

(Culver's Root.) 

The rhizome and roots of Veronica virginica, a perennial 
herb growing in the eastern portion of the United States. It 
contains a crystalline glucosid, leptandrin, which is to be dis- 
tinguished from an impure resin also known as leptandrin. 

Preparations. Dose. 

Fluidextractum Leptandrse, U. S. P 10-60 min. (0.6-4.0 c.c). 

Extractum Leptandrse, U. S. P 1-5 gr. (0.06-0.3 gm.). 

Pilulse Catharticae Vegetabiles, U. S. P. . . 1-3 pills. 

In the fresh state leptandra is a violent gastro-intestinal irri- 
tant. Preparations made of the dried root have a laxative or 
purgative effect, according to the dose, but they are somewhat 
uncertain in their action. Leptandra has been largely super- 
seded by more reliable remedies. 

FEL BOVIS, U. S. P. 

(Oxgall.) 

Purified oxgall (Fel Bovis Purificatum, U. S. P.) only is used 
in medicine. It is prepared by evaporating to a pilular con- 
sistence fresh oxgall that has been subjected for several days 
to the action of alcohol. It is a yellowish-green, soft solid, 
having a peculiar odor and a partly sweet and partly bitter 
taste. The dose is from 5-15 gr. (0.3-1.0 gm.). 

Physiologic Action and Therapeutics. — Bile is an 
active cholagogue and an uncertain laxative. That it is 
a true hepatic stimulant, increasing both the liquid and 
the solids secreted by the liver, has been amply confirmed 
by Rosenberg, Stadelmann, Joslin, and other investigators 
who have experimented on both animals and human beings 
with permanent biliary fistulae. When bile is not present in 
the intestines, the digestion of fat is materially aided by the 
administration of oxgall by the mouth. In the test-tube bile 
suspends peptic digestion by precipitating the soluble proteids 
(proteoses and peptones) and probably also pepsin ; but in the 



204 CATHARTICS. 

living subject, when the fat is excessive in the stools, it has 
been shown that it promotes the digestion of proteid food. 

Careful bacteriologic studies do not indicate that bile pos- 
sesses the pronounced antiseptic properties that are generally 
attributed to it. It is probable that the fetid character acquired 
by the stools in the absence of bile is due to impaired intestinal 
digestion, and, therefore, to better opportunities for the action 
of bacteria, rather than to the withdrawal of any antiseptic in- 
fluence exerted directly by the bile itself. 

Bile is too uncertain in its action to be employed as an 
ordinary laxative. In fecal impaction, however, a solution of 
oxgall, containing an ounce to a pint of water (30.0 gm.-o.5 
L.), often makes a very serviceable enema. When, for any 
reason, the biliary secretion is lacking in the intestine, oxgall 
may be used as an adjuvant to certain cathartics — podophyl- 
lum, jalap, rhubarb, and scammony — that are ordinarily inac- 
tive when bile is not present. 

In cases of biliary fistula or of obstruction of the common duct 
it may be used to promote the digestion of fats and proteids, 
and to prevent, indirectly, putrefactive changes in the intestinal 
contents. It is best administered in capsules, about two hours 
after meals. 

ALOE, U. S. P. 

(Aloes.) 

Aloes is the inspissated juice prepared from the leaves of 
several species of the genus Aloe, a familiar example of which 
is the American century plant. It contains a neutral crystal- 
line principle, aloin, a resin, and a trace of volatile oil. Aloin 
consists of a number of anthracene derivatives closely allied to 
those contained in rhubarb, cascara, and senna. It is less 
reliable than the crude drug. The dose of aloes is from 1-10 gr. 
(0.065-0.65 gm.). 

Preparations. Dose. 

Aloinum, U. S. P £-2 gr. (0.016-0. 13 gm.). 

Aloe Purificata, U. S. P 1-10 gr. (0.065-0.65 gm.). 

Tinctura Aloes, U. S. P \-2 fl. dr. (2.0-8.0 c.c). 

Tinctura Aloes et Myrrhse, U. S. P. ( 10 per 

cent, of each, with glycyrrhizse) |-2 fl. dr. (2.0-8.O c.c). 

Pilulse Aloes, U. S. P. (about 2 gr.— 0.13 gm.) 1-5 pills. 
Pilulse Aloes et Ferri, U. S. P. (about I gr. — 
0.065 gm. — each of aloes and ferrous sul- 
phate) 1-3 piUs. 

Pilulse Aloes et Mastiches, U. S. P. (Lady 
Webster's pills ; about 2 gr. — 0.13 gm. — of 
aloes, with mastich and red rose) .... 1-5 pills. 
Pilulse Aloes et Myrrhse, U. S. P. (2 gr. — 

0.13 gm.) 1-4 pills. 



ALOE. 205 

Preparations. Dose. 

Pilulae Laxativse Composite, U. S. P. {\ gr. — 0.013 gm. of 

aloin, with strychnin, extract of belladonna, and ipecac) . 1-3 pills. 
Pilulse Rhei Composite, U. S. P. {\\ gr.— 0.1 gm.— each) . 1-3 pills. 

Aloes also enters into compound extract of colocynth (50 
per cent.), compound tincture of benzoin (2 per cent.), com- 
pound cathartic pills, and vegetable cathartic pills. 

Physiologic Action and Therapeutics. — Aloes is a 
slowly acting but brisk purgative. A dose of 2 or 3 grains 
ordinarily produces one or two copious, dark-brown stools in 
the course of ten or twelve hours. The evacuation is gener- 
ally attended with more or less griping pain. Large doses 
congest the pelvic viscera and irritate the rectum. It has been 
shown that a part of that which is ingested escapes from the 
body in the urine, and, in the case of nursing women, in the 
milk. Aloes also causes catharsis when introduced into the 
system through channels other than the mouth, such as the 
skin and the rectum. When injected into the bowel, however, 
it is active only when combined with a solvent, like oxgall or 
glycerin. Aloin is slower in its action and somewhat less 
certain in its effects than aloes. Aloes is rarely used singly as 
a cathartic, but in simple, persistent constipation it is very effi- 
cacious in combination with other remedies, particularly with 
nux vomica, belladonna, ipecac, rhubarb, or podophyllum. 
Chlorosis with constipation often yields to pills of aloes and 
iron. Contrary to what was formerly believed, the use of aloes 
is not contraindicated by the existence of hemorrhoids unless 
inflammation has developed ; indeed, the drug often benefits 
indolent piles by overcoming the sluggishness of the bowel 
that led to their development. Since it congests the pelvic 
organs, aloes is sometimes serviceable as an emmenagogue in 
amenorrhea associated with troublesome constipation, and that 
is not dependent upon inflammation of the uterus or adnexa. 

When dysentery, cystitis, or inflammation of any pelvic 
organ is present, aloes should be avoided. On account of the 
possibility of its causing abortion it is best not to use it during 
pregnancy. 

Aloes is usually administered in the form of pills. The 
liquid preparations, on account of their disagreeable taste, are 
rarely employed. Meyer has shown that the action of the 
drug is increased by the addition of potassium carbonate or 
ferrous sulphate. 



206 CA THAR TICS. 

RHEUM, U. S. P. 

(Rhubarb.) 

Rhubarb is the root of Rheum officinale, and other species of 
Rheum, a perennial herb, resembling garden rhubarb, but of 
larger growth, and a native of China, Thibet, and other Asiatic 
countries. It contains a number of anthracene bodies {emodin, 
cathartin, and chrysophanic acid) and a considerable quantity of 
tannic acid. Chrysophanic acid has not the purgative action 
of the other anthracene bodies, owing to its rapid absorption. 
The dose of rhubarb is from 5-30 gr. (0.3-2.0 gm.). 

Preparations. Dose. 

Tinctura Rhei, U. S. P. (20 per cent., with 

cardamom) 1-2 fl. dr. (4.0-8.0 c.c). 

Tinctura Rhei Aromatica, U. S. P. (20 per 

cent., with aromatics) ^-1 fl. dr. (2.0-4.0 c.c). 

Fluidextractum Rhei, U. S. P 10-30 min. (0.6-2.0 c.c). 

Extractum Rhei, U. S. P 5-10 gr. (0.3-0.65 gm.). 

Mistura Rhei et Sodse, U. S. P. (1.5 per 
cent, of the fluid extract with sodium bi- 
carbonate, fluid extract of ipecac, and 
spirit of peppermint) £-2 fl. dr. (2.0-8.0 c.c). 

Syrupus Rhei, U. S. P. ( 10 per cent, of fluid 

extract) 1-6 fl. dr. (4.0-22.5 c.c). 

Syrupus Rhei Aromaticus, U. S. P. (spiced 
syrup of rhubarb : 15 per cent, of aromatic 
tincture) 1-6 fl. dr. (4.0-22.5 c.c). 

Pulvis Rhei Compositus, U. S. P. (Gregory's 
powder : rhubarb, 25 ; magnesia, 65 ; gin- 
ger, 10) 20-60 gr. (1.3-4.0 gm.). 

Pilulse Rhei Composite, U. S. P. (rhubarb, 2 
gr. — 0.13 gm. ; aloes, i\ gr. — 0.1 gm. ; 
myrrh; and oil of peppermint) .... 1-5 pills. 

Physiologic Action and Therapeutics.— In appropriate 
doses rhubarb acts as a purgative and stomachic. It affects 
the bowel more promptly than aloes, a full dose of from 20- 
30 gr. (1.3-2.0 gm.) usually producing evacuation in from four 
to eight hours. On account of the tannic acid that it contains 
it frequently causes constipation as a secondary effect. Doses 
of from 1-3 gr. (0.065-0.2 gm.) often exert no cathartic influ- 
ence, but act upon the stomach as a tonic and mild astringent. 
It is eliminated in the various secretions — urine, milk, and 
sweat — and imparts to them a yellowish color. 

Rhubarb is an excellent remedy for removing irritant ma- 
terial from the bowel in the beginning of acute diarrhea. In 
the dyspeptic diarrhea of childhood the withdrawal of all food 
for several hours and the administration of a few doses of the 
aromatic syrup with magnesia generally affords prompt 
relief: 



SENNA. 207 

$ Magnesii oxidi, gr. x l ( 2 .6 gm.) ; 

Syrupi rhei aromatici, f^vj (22.5 c.c); 

Aquae menthae piperitae, q. s. ad ff j (30.0 c.c). — M. 

Sig. A teaspoonful repeated once or twice for a child two years old. 

Rhubarb alone is not a suitable remedy for chronic consti- 
pation, but benefit is often derived from a combination of small 
doses with other cathartics. Mild attacks of indigestion the 
result of overindulgence, frequently yield to the union of rhu- 
barb with an antacid : 

& Pulveris nucis vomicae, gr. xii (0.8 gm.); 

Pulveris rhei, gr. xxiv (1.5 gm.) ; 

Sodii bicarbonatis, ^j (4.0 gm.). — M. 

Fiant chartulae No. xii. 
Sig. One before meals. 

SENNA, U. S. P. 

Senna is the leaflets of Cassia acutifolia and of Cassia 
angustifolia, small shrubs growing respectively in Africa and 
India. It contains a number of anthracene bodies, chief of 
which is cathartin or carthartinic acid. The dose is from 1—3 
dr. (4.0-12.0 gm.). 

Preparations. Dose. 

Fluidextractum Sennae, U. S. P 1-2 fl. dr. (4.0-8.0 c.c). 

Syrupus Sennae, U. S. P. (25 per cent.) . . . 1-4 fl. dr. '4.0-16.0 c.c). 
Infusum Sennae Compositum, U. S. P. (Black 

Draft: senna, 6; fennel, 2; manna, 12; 

Epsom salts, 12) 1-4 fl. oz. (30.0-120.0 c.c). 

Confectio Sennae, U. S. P. (10 per cent., 

wilh cassia fistula, tamarind, prune, fig, 

sugar, and coriander oil) 1-2 dr. (4.0-8.0 gm.). 

Pulvis Glycyrrhizae Compositus, U. S. P. (18 

per cent, of senna, with licorice, sulphur, 

sugar, and fennel oil) ... ^-2 dr. (2.0-8.0 gm.). 

Senna (1.5 per cent of the fluid extract) also enters into 
compound syrup of sarsaparilla. 

Physiologic Action and Therapeutics. — Senna is an 
energetic purgative. A full dose produces in from four to six 
hours one or two yellowish, loose, or even watery, stools, the 
evacuation being attended with considerable griping and flat- 
ulence. Its action is more irritating than that of rhubarb, 
and more prompt and powerful than that of aloes. Very 
large doses cause nausea, vomiting, violent purging, and 
depression. Cathartinic acid also acts when injected subcu- 
taneously. Like rhubarb, senna imparts to the urine a deep 
yellow or red color, the pigmentation being due to the pres- 
ence of chrysophanic acid. Senna is a safe and reliable purga- 
tive for unloading the bowel in simple, acute constipation. Its 



208 CATHARTICS. 

tendency to cause griping is in a measure corrected by giving 
it with an aromatic or a saline. Compound licorice powder, 
in doses of a teaspoonful, more or less, at bedtime, is a popu- 
lar household remedy in habitual costiveness. 

PHENOLPHTHALEIN. 

(Purgen.) 

Phenolphthalein is an artificial anthracene derivative, pre- 
pared by the interaction of phenol and phthalic anhydride. It 
is a white crystalline powder, soluble in 600 parts of water and 
in 10 of alcohol. The dose is from 1 to 8 gr. (0.6-0.5 gm.) in 
powder, capsule, or pill. 

Phenolphthalein is an agreeable, fairly reliable, but slowly 
acting purgative. In the doses indicated it appears to have no 
other action. 

OLEUM RICINI, U. S. P. 

(Castor Oil.) 

Castor oil is a fixed oil expressed from the seed of Ricinus 
communis, a plant indigenous to India, but extensively culti- 
vated in other countries having a warm or temperate climate. 
It is a pale-yellowish, viscid oil, having a faint odor and a 
slightly acrid, offensive taste. It is freely soluble in alcohol. 
It is composed chiefly of ricinolein, the glycerid of ricinoleic 
acid, which is the purgative principle. The seeds themselves 
are never used for medicinal purposes. They contain ricin, 
an intensely poisonous proteid body, which, when injected 
into the blood of an animal, causes, after the lapse of several 
days, anorexia, vomiting, diarrhea, and profound prostration. 
In fatal poisoning the chief postmortem lesions are extensive 
ecchymoses of the mucous and serous membranes, tumefac- 
tion of the abdominal lymph-glands, and numerous areas of 
necrosis in the various organs. The dose of castor oil for an 
infant is from 1-2 dr. (4.0-8.0 c.c); for an adult, ^-1 ounce 
(15.0-30.0 c.c). 

Physiologic Action and Therapeutics. — Castor oil is 
a mild purgative, unloading the bowels thoroughly in from 
four to six hours, without causing much colic or flatulence. 
While its fate in the body has not been definitely determined, 
it is probable that it escapes from the stomach unchanged, 
and that in the presence of the intestinal juices saponification 
occurs with the liberation of ricinoleic acid, which is subse- 
quently converted into ricinoleates. The latter induce catharsis 
by stimulating the muscular coat of the bowel, and are proba- 



HYDRARGYRI CHLORIDUM MITE. 209 

bly absorbed, since the oil is known to impart its purgative 
properties to the milk when given to nursing women. 

Castor oil is not a suitable remedy for habitual constipa- 
tion, but on account of its mild and speedy action it is perhaps 
the best remedy we possess to remove irritant material from 
the bowel in the beginning of acute inflammatory diarrhea. It 
is also an excellent laxative for use during pregnancy or labor. 

When it is desirable to add an oil to a lotion intended for 
the scalp, castor oil is generally selected on account of its 
solubility in alcohol. 

The leaves of the castor oil plant are said to promote the 
flow of milk when applied to the breasts. 

Many substances have been suggested to disguise the dis- 
agreeable taste of castor oil, which is the main objection to its 
employment; those in common use are the oils of pepper- 
mint, gaultheria, and cinnamon. Wood speaks favorably of a 
combination of equal parts of glycerin and castor oil flavored 
with a drop or two of one of the above-named oils. It is 
often given in the froth of porter, beer, or soda-water. It may 
be prescribed in emulsion, but in this form it is bulky and not 
so effective. The best method of administering it is in flexi- 
ble capsules containing a dram (3C.0 c.c.) or more. 

HYDRARGYRI CHLORIDUM MITE, U. S. P. 

(Mild Mercurous Chlorid; Calomel; Hg 2 Cl 2 .) 

Calomel is a white, odorless, tasteless powder, insoluble in 
all ordinary menstrua. The dose is from yV -10 § r - (0.0065- 
0.65 gm.). 

Preparations. Dose. 

Pilulae Antimonii Composite (Plummer's Pills; § gr. — 0.04 
gm. — of calomel and sulphurated antimony with guaiac 
and castor oil) 1-2 pills. 

Pilulae Cathartics Composite, U. S. P. (1 gr. — 0.06 gm. — 
of calomel, with gamboge, compound extract of colocynth, 
and extract of jalap) 1-3 pills. 

Calomel acts as a laxative or as a purgative according to 
the method of its administration and the susceptibility of the 
patient Unlike other cathartics, its effect does not increase 
in direct ratio with the dose. Fractional doses repeated every 
half hour until 1 or 2 gr. (0.065-0.13 gm.) have been taken 
generally operate more freely than a dose of 10 gr. (0.65 gm.) 
taken at once. Calomel produces a thorough evacuation, the 
stools being large and loose, and commonly charged with 
undecomposed bile. Its action is not usually accompanied 

14 



2IO CATHARTICS. 

by much griping, but in some persons the drug excites more 
or less nausea. The change that calomel undergoes in the 
body is still a matter of dispute. It was formerly supposed 
that at least a portion was converted into mercuric chlorid by 
the hydrochloric acid of the stomach, but the experiments of 
Bucheim, Winkler, and Jeannel prove that such a conversion 
is impossible at the temperature of the body. It is more 
probable, as Jeannel suggests, that in the presence of the alka- 
line juices of the intestines the drug is changed into a gray 
oxid, a compound that is freely soluble in oily alkaline mix- 
tures, such as are naturally present in the duodenum. Whether 
or not calomel directly increases the secretion of bile is 
another question that has evoked considerable discussion, and 
to which no definite answer can be given at the present time. 
There can be no doubt that the amount of bile discharged in 
the stools is actually increased under its influence, but the 
evidence, experimental and clinical, does not favor the view 
that calomel increases the quantity of bile formed by the liver ; 
on the contrary, it suggests that the drug, through its stimu- 
lant action on the duodenum, merely speeds the flow of bile 
through the intestines and prevents its reabsorption. 

No remedy is so useful as calomel in the condition known 
zs" biliousness" which is characterized by a thickly coated 
tongue, fetid breath, heavy urine, headache, and depression 
of spirits. A sixth of a grain (o.Oi gm.) may be given every 
fifteen or twenty minutes until I gr. (0.065 gm.) has been 
taken. If the bowels do not move freely, the mercurial may 
be followed by Epsom salts or a Seidlitz powder. Attacks 
of indigestion associated with clay-colored stools, in either 
children or adults, are often relieved by a few small doses 
of calomel. In dyspeptic diarrhea it is not quite so effica- 
cious as castor oil in removing undigested food from the 
bowel, but it has advantages in its tastelessness and small 
bulk. In the beginning of acute disease, especially the specific 
infections, it is an excellent cathartic for unloading the bowels 
without exciting irritation. In chronic heart disease with 
venous engorgement of the digestive organs calomel is of the 
utmost value in relieving the tension in the portal circulation, 
and without its aid digitalis often proves ineffectual. 

Massa Hydrargyri, TJ. S. P. (Blue Mass) is made by 
triturating mercury, 33 ; glycyrrhiza, 10 ; althaea, 15 ; glycerin, 
9; and honey of rose, 33. It is employed for the same pur- 
poses as calomel, although it is less active. The dose is from 
^—15 gr. (0.0 1 6-1.0 gm.). 

Hydrargyrum cum Creta, TJ. S. P. (mercury with chalk ; 



OLEUM TIG LI I. 211 

gray powder). — This is an intimate mixture of mercury, honey, 
and chalk, containing 38 per cent, of mercury. It is weaker 
than blue mass. The dose is from 1-10 gr. (0.065-0.65 gm.). 

OLEUM TIGLII, U. S. P. 

(Croton Oil.) 

Croton oil is a fixed oil expressed from the seeds of Croton 
Tiglium, a small tree, indigenous to China, but extensively cul- 
tivated in India and the Philippine Islands. It is a yellowish, 
viscid oil, having a faint odor and an acrid, burning taste. In 
addition to several inactive fatty acids it contains crotonoleic 
acid, which is present both as a free acid and as a glycerid. 
The dose of the oil is from -J— 2 min. (0.03-0.12 c.c). 

Physiologic Action and Therapeutics. — When applied 
to the skin, croton oil causes redness and burning, followed by 
a copious eruption of pustules. When taken internally, it acts 
as a violent drastic cathartic, causing in from one to two hours 
several copious movements, which are partly formed and 
partly watery. The evacuations are usually attended with 
considerable pain, and not infrequently with nausea. Large 
doses produce all the symptoms of a severe gastro-enteritis. 
As croton oil contains a certain amount of free crotonoleic 
acid, it causes, when swallowed without a demulcent, a burn- 
ing sensation in the fauces and stomach, but its maximum irri- 
tant effect is not manifested until it reaches the intestine, where 
the bulk of the acid is liberated from the oil by saponification. 

On account of the ease with which it can be administered 
croton oil is a well-adapted cathartic for cases in which deglu- 
tition is seriously affected. Its prompt irritant action on the 
bowel makes it also a useful revulsant in cases of cerebral 
congestion. Thus, it may be given with advantage in uremia, 
apoplexy, and acute mania. 

It is also useful in very obstinate constipation, such as occurs 
in chronic lead-poisoning. As it acts promptly when simply 
placed on the back of the tongue, it is often selected as a 
cathartic for the insane. Its use is contraindicated whenever 
there is inflammation of the gastro-intestinal tract. 

The drug is best administered in a little olive oil or in a 
pill with bread-crumb as an excipient. 

Croton oil is sometimes used externally as a counterirritant. 
It is rarely applied to the skin in the pure state, a mixture with 
from 2 to 4 parts of some indifferent oil generally being pre- 
ferred. A liniment is official in the British Pharmacopoeia 
that is made of 2 parts of the oil with 7 parts each of oil of 



212 CATHARTICS. 

cajuput and alcohol. This liniment may be applied to the 
chest in chronic bronchitis, phthisis, or fibrinous pleurisy. 

A mixture of croton oil (i part) and tincture of iodin 
(3 parts) employed as a pigment often acts very well in 
neuritis. 

COLOCYNTHIS, U. S. P. 

(Colocynth.) 

Colocynth is the fruit of Citrullus Colocynthis deprived of its 
rind. The plant grows in arid places in Asia, Africa, and 
Southern Europe. The chief cathartic principle is colocynthin, 
a bitter glucosid. 

Preparations. Dose. 

Extractum Colocynthidis, U. S. P 2-5 gr. (0.13-0.3 gm.). 

Extractum Colocynthidis Compositum, U. S. P. 

(extract of colocynth, 16; aloes, 50; resin of 

scammony, 14; cardamom, 6; soap, 14) . . 5-20 gr. (0.3-1.3 gm.). 
Pilulae Catharticae Composite, U. S. P. (each pill 

contains about 1^ gr. — 0.08 gm. — of compound 

extract of colocynth; I gr. — 0.06 gm. — of 

calomel ; \ gr. — 0.02 gm. — of resin of jalap ; 

\ gr. — 0.015 gm. — of gamboge) 1-3 pills. 

PiJulse Catharticae Vegetabiles, U. S. P. (each pill 

contains about 1 gr. — 0.06 gm.— of compound 

extract of colocynth ; \ gr. — 0.02 gm. — of resin 

of jalap; \ gr. — 0.03 gm. — of extract of hyos- 

cyamus; \ gr. — 0.015 gm. — of extract of lep- 

tandra; \ gr. — 0.015 g m - — °f resin of podo- 
phyllum ; oil of peppermint 1-3 pills. 

Physiologic Action and Therapeutics. — Colocynth is 
a powerful drastic cathartic, producing in full doses copious 
watery stools, which are often accompanied by griping. Very 
large doses excite intense inflammation of the whole alimen- 
tary tract, which may prove fatal. The drug is too irritant to 
be used alone. At the present time it is prescribed in combi- 
nation with other remedies only in obstinate chronic constipa- 
tion. It is not a suitable cathartic for habitual use, but it may 
be employed now and then to secure a thorough evacuation 
of the bowels. 

CAMBOGIA, U. S. P. 

(Gamboge.) 

Gamboge is a gum-resin from Garcinia Hanburii, a laurel- 
like tree growing in the East Indies. Its active principle is 
cambogic acid. The dose is from -|— 5 gr. (0.03-0.3 gm.). 

Preparation. Dose. 

Pilulae Catharticae Compositae, U. S. P. (about \ gr. — 0.015 

gm. — in each pill) 1-3 pills. 



SCAMMONIUM—PODOPHYLL UM. 2 1 3 

Physiologic Action and Therapeutics. — Gamboge is 
an extremely irritating drastic cathartic, fully capable in large 
doses of causing fatal gastro-enteritis. It is never used alone, 
but in combination with less powerful cathartics it is some- 
times employed in obstinate chronic co?istipation. 

SCAMMONIUM, U. S. P. 

(Scammony.) 

Scammony is a resinous exudation from the living root of 
Convolvulus Scammonia, a perennial herb growing in Western 
Asia. Its active principle is a resin, scammonin, which appears 
to be identical with jalapin. The dose of scammony is from 
I- IO gr. (0.06-0.6 gm.). 

Preparations. Dose. 

Resina Scammonii, U. S. P 2-8 gr. (0.13-0.5 gm.). 

Extractum Colocynthidis Composition, U. S. P. 

(14 per cent.) 5-20 gr. (0.3-1.3 gm.). 

Physiologic Action and Therapeutics. — Scammony 
has been used as a drastic cathartic since the time of Hip- 
pocrates. It is more powerful than jalap, but less irritating 
than gamboge. It is rarely employed except in the form of 
the " compound cathartic pill." 

PODOPHYLLUM, U. S. P. 

(May Apple; Mandrake.) 

Podophyllum is the rhizome and roots of Podophyllum 
peltatum, a perennial herb growing in moist shady places in 
Canada and Northern United States. It contains two isom- 
eric glucosids — podophyllotoxin and picropodophyllin. 

Preparations. Dose. 

Resina Podophylli, U. S. P. (Podophyllin) . \-\ gr. (0.008-0.03 gm.). 

Fluidextractum Podophylli, U. S. P 5-20 min. (0.3-1.2 c.c.). 

Pilulse Podophylli, Belladonna; et Capsici, 

U. S. P. (each pill contains \ gr. (0.016 

gm.) of resin of podophyllum, \ gr. (0.008 

gm.) of extract of belladonna, and J gr. 

(0.32 gm.) of capsicum) 1—2 pills. 

The resin also enters into vegetable cathartic pills. 

Physiologic Action and Therapeutics. — In full doses 
podophyllum is an active, irritant cathartic. It produces its 
effects slowly, however — rarely earlier than ten or twelve hours 
after its administration — the evacuations being copious and 
liquid, and generally attended with much griping pain. It is 
said to act as a cathartic when applied to an open wound or 



214 CATHARTICS. 

administered subcutaneously. It is believed by many prac- 
titioners to possess the power of directly increasing the 
secretion of bile, but very little evidence can be adduced to 
support this claim. 

Podophyllum is especially prized as a cathartic in habitual 
constipation, associated with so-called " bilious attacks." To 
many persons the action of the drug is very agreeable, but in 
others it causes severe pain and depression. When combined 
with other cathartics only those should be selected which are 
also slow in action, such as aloes and calomel. Extract of 
belladonna or hyoscyamus may be added to prevent griping. 
The resin is the most reliable preparation. A combination 
like the following often makes a useful dinner pill : 

R Resinae podophylli, gr. iv (0.26 gm.): 

Aloes purificatae, gr. xx-xl (1.3-2.6 gm.) ; 

Extracti nucis vomicae, 

Extracti belladonnas, aa gr. iv (0.26 gm.). — M. 

Fiant pilulae No. xx. 

Sig. One at bedtime. 

JALAPA, U. S. P. 

(Jalap.) 

Jalap is the dried tuberous root of Exogonium Purga, a 
perennial herb growing in Mexico. It contains two active 
glucosids, convolvulin and jalapin. The dose is from 5-30 gr. 
(0.3-2.0 gm.). 

PreparationSo Dose. 

Resina Jalapae, U. S. P 1-5 gr. (0.065-0.3 gm.). 

Pulvis Jalapae Compositus, U. S. P. (35 per 

cent, of jalap and 65 per cent, of potassium 

bitartrate) 15-60 gr. (1.0-4.0 gm.). 

Pilulae Catharticae Compositae, U. S. P. (£ gr. 

— 0.02 gm. — of extract) 1-3 pills. 

Pilulae Catharticae Vegetabiles, U. S. P. (£ gr. 

— 0.02 gm. — of extract) 1-3 pills. 

Physiologic Action and Therapeutics. — Jalap is a 
powerful hydragogue cathartic. It acts generally within three 
or four hours, and produces copious watery stools. It not 
infrequently excites nausea and colic, but its action is less 
harsh than that of either gamboge or scammony. According 
to Stadelmann, it is inactive in the absence of bile, the latter 
probably serving as a solvent. Except as an ingredient of 
" compound cathartic pills " or " vegetable cathartic pills " 
jalap is not employed in simple constipation. It is used espe- 
cially for the removal of dropsical effusions, and for this pur- 
pose it is frequently combined with a saline, as in the official 
compound jalap powder. Associated with calomel jalap is 



ELATERIUM— BRYONIA. 21 5 

sometimes a valuable depletive in chronic heart disease with 
congestion of the portal circulation. 



ELATERIUM. 

Elaterium is a substance deposited by the juice oi Ecb allium 
Elaterium y or squirting cucumber, a vine growing on the shores 
of the Mediterranean Sea. It is of uncertain strength and is 
not official, but its active properties are fully represented by a 
neutral principle, elaterin (Elaterinum, U. S. P.), which is official. 
The latter occurs in minute white scales or crystals, without 
odor, and having an acrid, bitter taste. It is almost insoluble 
in water, but readily soluble in chloroform and hot alcohol. 
The dose of elaterium is from \-\ gr. (0.008-0.03 g m -)- 

Preparations. Dose. 

Elaterinum, U. S. P irWV S 1 *- (0.002-0.0065 gm.). 

Trituratio Elaterini, U. S. P. (10 per cent., 

with sugar of milk) \-\ gr. (0.016-0.065 gm.). 

Physiologic Action and Therapeutics. — Elaterium is 
a decided irritant to all tissues. Given internally it is, perhaps, 
the most powerful of the hydragogue cathartics, producing 
large watery stools, with some griping, and, occasionally, 
nausea. Its action is more vigorous than that of jalap and 
less harsh than that of gamboge or colocynth. In overdoses 
it is a violent, acrid poison. 

In appropriate doses elaterium is often very useful in reduc- 
ing local serous effusions (hydrothorax, hydropericardium, 
ascites) and the general dropsy of cardiac or renal disease. On 
account of its prompt action it may be employed also as a 
derivative in cerebral congestion and uremia. Elaterium itself, 
probably on account of its adulteration, is unreliable, and, 
therefore, only official preparations should be prescribed. 

BRYONIA. 

(Bryony.) 

Bryonia is the root of Bryonia alba and of Bryonia dioica t 
a perennial climbing plant growing in Central and Southern 
Europe. Its active principle is probably bryonin, an intensely 
bitter, soluble glucosid. 

Preparation. Dose. 

Tinctura Bryoniae I -2 fl. dr. (4.0-8.0 c.c). 

Bryonia is a drastic, hydragogue cathartic. It was formerly 



2l6 CATHARTICS. 

a much esteemed remedy in general dropsy and local effusions, 
but at present it is very rarely used. 

MAGNESII SULPHAS, U. S. P. 

(Magnesium Sulphate; Epsom Salt; MgS0 4 + 7H 2 0.) 

Magnesium sulphate occurs in small, colorless, rhombic 
prisms or acicular crystals, odorless, and having an unpleasant, 
bitter, saline taste. It is soluble in 1.5 parts of water, and in- 
soluble in alcohol. The dose is from 1-8 dr. (4.0-30.0 gm.). 

Preparations. Dose. 

Magnesii Sulphas Effervescens, U. S. P. . . 1-8 dr. (4.0-30.0 gm.). 
Infusum Sennae Compositum ( 1 2 per cent.), 

U. S. P 1-4 fl. oz. (30.0-120.0 c.c). 

Physiologic Action. — The saline cathartics, of which 
magnesium sulphate may be taken as a type, produce evacua- 
tion of the bowels chiefly by increasing the amount of fluid in 
the intestine. Unlike the vegetable cathartics, they are but 
feeble stimulants to peristalsis. They hinder the absorption 
of fluid taken with food, and they also abstract fluid directly 
from the tissues and blood. The increased bulk and weight 
of the intestinal contents give an impetus to peristalsis and 
purgation follows, but there is little direct irritation of the mus- 
cular coat of the bowel, as occurs with the vegetable cathartics. 
Under ordinary conditions saline cathartics are absorbed 
from the intestine very slowly and in but small quantities, the 
greater part escaping from the body in the stools. Their 
action, therefore, appears to be a purely local one, and this 
view is supported by the fact that they do not produce catharsis 
when injected intravenously. It is a noteworthy fact that when 
a saline cathartic is administered to an anhydremic subject, 
instead of the blood yielding its water to the intestine, the 
process is reversed, and the blood attracts fluid from the bowel, 
the salt is in large part absorbed, and purgation does not ensue. 

Saline cathartics, by concentrating the blood, primarily 
lessen the secretion of urine ; subsequently, however, they 
may be absorbed from the intestine in sufficient quantity to 
exert a diuretic effect. 

In full doses and in concentrated solution magnesium sul- 
phate is an active hydragogue cathartic, producing in the 
course of a few hours copious watery stools without much 
pain or systemic disturbance. Its chief drawback is its ten- 
dency to excite nausea. Dilute solutions are much less active 
as purgatives, but, being more readily absorbed, they increase 



MAGNESII SULPHAS. 21 J 

the flow of urine. Meltzer has shown that magnesium 
salts, when injected intravenously, inhibit the respiration 
and cause paralysis of the entire body ; that, when applied 
directly to a nerve, they produce complete nerve block, and 
that, when injected into the spinal meninges, they cause gen- 
eral anesthesia, muscular relaxation, and sleep lasting for sev- 
eral hours. 

Therapeutics. — Since Epsom salt is free from irritant 
properties, it is an excellent cathartic for removing undigested 
material from the bowel in acute enteritis and colitis. On 
account of its unpleasant taste and large bulk, however, it is 
not so convenient for children as calomel, or even castor oil. 
As it increases the fluidity of the intestinal contents it is well 
suited for use in cases of fecal accumulation. In chronic con- 
stipation a saline taken in small dose before breakfast is some- 
times more efficacious than a vegetable cathartic. It is an 
excellent remedy for reducing dropsical effusions, both local 
and general. Recently several competent observers have tes- 
tified to the value of Epsom salt in the treatment of tropical 
dysentery. Doses of from 1-2 dr. (4.0-8.0 gm.) are recom- 
mended to be given in some aromatic water, and continued 
until the stools lose their mucous character. 

Magnesium sulphate is also used as an antidote to acute 
lead-poisoning and to carbolic acid poisoning. With sugar of 
lead it forms an insoluble sulphate, and with carbolic acid an 
innocuous phenolsulphonate. 

As a result of Meltzer's observations, intraspinal injections 
of Epsom salt (2-4 c.c. of a 25 per cent, solution) have been 
employed to some extent in controlling the convulsions of teta- 
nus. Although the treatment seems to have been decidedly 
beneficial in a number of severe cases, great caution is urged 
in adopting it, owing to the frequency with which marked 
depression of the respiration occurs. 

Administration. — When a full hydragogue effect is de- 
sired, the drug should be given before breakfast, in one 
large dose, and with but a small quantity of water. In 
cases of general dropsy the restriction of liquids after 
the administration of the salt makes its action still more 
effective. Solutions of Epsom salt are rendered more accept- 
able to the stomach by the addition of magnesium carbonate 
(20-30 gr. — 1.3-2.0 gm.). Cathartic enemata are rendered 
more active by the addition of Epsom salt. The following 
enema, recommended by Noble, will be found very efficacious 
in cases of marked intestinal torpor : 



2l8 CATHARTICS. 

R Magnesii sulphatis, !|ij (60.0 gm.) ; 

Olei terebinthinae, fSss (15.0 c.c); 

Glycerini, ffj (30.0 c.c); 

Aquas, q. s. ad fgiv (120.0 c.c). — M. 

Incompatibles. — Magnesium sulphate is incompatible 
with lead acetate, silver nitrate, alkaline carbonates, and lime- 
water. From solutions of sodium phosphate it precipitates 
the insoluble magnesium phosphate, and from solutions of 
Rochelle salt, after a time, the insoluble magnesium tar- 
trate. 

SODII SULPHAS, U. S. P. 

(Sodium Sulphate; Glauber's Salt ; Na 2 S0 4 +ioH 2 0.) 

Sodium sulphate occurs in large, colorless, transparent 
prisms, or granular crystals, odorless, and of a bitter, saline 
taste. It is soluble in 2.8 parts of water. The dose is from 
2-8 dr. (8.0-30.0 gm.). 

Therapeutics. — Glauber's salt is a powerful hydragogue 
cathartic, producing large watery stools, accompanied by 
griping and borborygmi. Epsom salt, being far less irritating, 
has largely superseded it. It enters into the mixture known 
as artificial Carlsbad salt, which makes an efficient mild saline 
aperient : 

R Sodii sulphatis, ^v (150.0 gm.) ; 

Sodii bicarbonatis, ^ij (60.0 gm.) ; 

Sodii chloridi, g] (30.0 gm.). — M. 

Sig. A teaspoonful in a tumblerful of hot water half an hour before 
breakfast. 

The sulphates of sodium and magnesium are the active 
ingredients in certain natural mineral waters, such as Hun- 
yadi Janos, Friedrichshall, Carlsbad, Rubinat, and Pullna. 

POTASSII ET SODII TARTRAS, U. S. P. 

(Potassium and Sodium Tartrate ; Rochelle Salt; KNaC 4 H 4 6 + 4H 2 0.) 

Rochelle salt occurs in colorless, transparent, prismatic 
crystals, or as a white powder, odorless, and having a cooling, 
saline taste. It is soluble in 1.2 parts of cool water and in 
less than 1 part of boiling water. The dose is from 1-4 dr. 
(4.0-16.0 gm.). 

Preparation. Dose. 

Pulvis Effervescens Compositus, U. S. P. (Seidlitz powder) . 1 powder. 

(The blue paper contains sodium bicarbonate, 40 gr. — 2.6 gm. — and potassium 
and sodium tartrate, 120 gr. — 8.0 gm. The white paper contains tartaric acid, 35 
gr. — 2.3 gm. The contents of each paper should be dissolved separately, the two 
solutions mixed, and the whole taken while effervescing.) 



SOD II PHOSPHAS—MAGNESII CITRAS. 2 1 9 

Therapeutics. — Rochelle salt may be used as a hydra- 
gogue cathartic in the same class of cases in which magne- 
sium sulphate is indicated. It is less active than the latter 
salt, but more agreeable to take. Seidlitz powder is a very 
mild saline cathartic. The carbonic acid evolved during effer- 
vescence not only makes the solution palatable, but exerts a 
sedative influence on the stomach. 

SODII PHOSPHAS, U. S. P. 

(Sodium Phosphate; Na 2 HP0 4 +l2H 2 0.) 

Sodium phosphate occurs in large, colorless, prismatic crys- 
tals, odorless, and having a cooling, saline taste. It is solu- 
ble in 5.5 parts of water, and insoluble in alcohol. The dose 
for a young child is from 1-10 gr. (0.065-0.65 gm.); for an 
adult, J-4 dr. (2.0-16.0 gm.). 

Preparations. Dose. 

Sodii Phosphas Effervescens, U. S. P. ... 1-8 dr. (4.0-30.0 gm.). 

Sodii Phosphas Exsiccatus, U. S. P 1 0-60 gr. (0.65-4.0 gm.). 

Liquor Sodii Phosphatis Compositus, U. S. P. 

(each fl. dr. (4.0 c.c.) contains I dr. 

(4 gm.) of sodium phosphate, with citric 

acid and sodium nitrate) 1-3 fl. dr. (4.0-1 1.0 c.c). 

Therapeutics. — Sodium phosphate in small doses acts as 
a laxative ; in large doses, as a purgative. Its mild action and 
agreeable taste commend it especially for children, to whom 
it may be given in milk or other food. It is useful also in the 
less severe forms of constipation occurring in adults. In 
chronic gastric catarrh with constipation small doses in hot 
water before meals often have a very happy effect not only on 
the bowel, but also on the stomach. Taken in the same way, 
sodium phosphate is a valuable depletive in simple catarrhal 
jaundice secondary to duodenitis. 

MAGNESII CITRAS. 

(Magnesium Citrate; Mg 3 2C 6 H 5 7 + i4H 2 0.) 

Magnesium citrate is official as the solution of magnesium 
citrate (Liquor Magnesii Citratis). This preparation is an 
effervescing solution of magnesium citrate containing a small 
quantity of sugar and free citric acid. In doses of from 
6-12 fl. oz. (180.0-360.0 c.c.) it is a very pleasant, but some- 
what irritating, cathartic. It is suitable for occasional use, 
when it is desired simply to evacuate the alimentary canal. 
It should not be employed when there is any inflammation of 
the gastro-intestinal tract. 



220 DIURETICS. 

DIURETICS. 

Diuretics are agents that increase the flow of urine. They 
may act (i) by increasing the general arterial pressure; (2) by 
dilating the vessels of the kidney ; (3) by increasing the water 
content of the blood (salt action) ; (4) by directly stimulating 
the renal epithelium. 

(1) General Circulatory Stimulants. — The chief representa- 
tives of this class of diuretics are : 

Digitalis. Convallaria. 

Strophanthus. Apocynum. 

Squill. 

Part of the diuretic effect of squill is to be attributed to direct 
stimulation of the renal epithelium. 

Dilators of the Renal Vessels. — Local dilatation of the vessels 
of the kidney, if not accompanied by a reduction of the general 
arterial pressure, increases the secretion of urine. There is 
some reason to believe that the purin derivatives — caffein, 
theobromin, theophyllin — increase urine production, partly by 
inducing local changes in the renal circulation. 

Salines. — Salts that are readily absorbed from the aliment- 
ary canal cause diuresis by drawing water into the blood and 
distending the renal vessels. Salts that are difficult of absorp- 
tion, like the magnesium and sulphate ions, draw water into the 
bowel and act as cathartics. The following drugs owe their 
diuretic properties to salt action : 

Potassium bicarbonate. Potassium nitrate. 

Potassium carbonate. Potassium chlorate. 

Potassium bitartrate. Lithium carbonate. 

Potassium acetate. Lithium citrate. 

Potassium citrate. Lithium benzoate. 

Dextrose and other sugars, owing to their high osmotic equiv- 
alents, also induce diuresis, hence the polyuria of diabetes mellitus. 
Direct Renal Stimulants. — The chief members of this group 
are : 

Caffein. Calomel. 

Theobromin. Blue mass. 

Theophyllin. Scoparius. 

As pointed out above, there is some evidence to show that 
caffein, theobromin, and theophyllin act partly by dilating the 
kidney vessels. 



DIURETICS. 221 

Buchu, uva ursi, oil of turpentine, copaiba, and cubeb also 
have a specific effect on the renal epithelium, but they are 
used chiefly to stimulate the mucous membrane of the genito- 
urinary tract and to inhibit bacterial growth in the urine and 
very rarely as diuretics. They are considered under the heading 
" Stimulants to the Genito-urinary Tract." 

Concerning the influence of drugs upon the solids eliminated 
by the kidneys, we have at present very little definite knowl- 
edge. Large quantities of water frequently increase the solids 
of the urine, but it has been shown that this is due to the flush- 
ing out of waste-products and not to any increase of proteid 
metabolism. It is commonly believed that the alkaline diuretics 
hasten oxidation in the tissues, and in consequence increase 
nitrogenous elimination, but it has not been satisfactorily dem- 
onstrated that these drugs have such an action. Many of the 
investigations undertaken to decide the question have been 
attended by numerous opportunities for error, and those that 
have not been have given such conflicting results that no con- 
clusions can be drawn from them. 

Digitalis, strophantus, and caffein have no pronounced effect 
on the excretion of the solids normally found in the urine, but 
the last sometimes induces a slight glycosuria. 

Certain drugs which have no special activity as diuretics 
notably increase the solid constituents of the urine. Thus, 
salicylic acid increases the elimination of urea, uric acid, and 
sulphur compounds ; colchicum probably increases the excre- 
tion of uric acid, and thyroid extract, by increasing the 
destruction of the proteids of the tissues, very decidedly 
augments the output of nitrogen and phosphates. 

Diuretics are employed for the following purposes : 

1. To Remove Excrementitious Matters From the Blood. — 
They are useful for this purpose when the secretory function 
of the kidneys is impaired or suspended, as it often is in acute 
febrile diseases, in passive congestion of the kidneys, and in 
some forms of Bright's disease. 

2. To Promote the Absorption and Excretion of Dropsical 
Effusion. — For obvious reasons diuretics are less efficacious in 
dropsy resulting from organic disease of the kidneys than in 
that resulting from lowered arterial tension. 

3. To Lessen Irritation of the Genito-urifiary Tract. — For 
this purpose alkaline diuretics are useful when the urine is too 
concentrated or is excessively acid. They also relieve the 
distressing symptoms occasioned by uric acid gravel and uric 
acid stones, not by exercising a solvent action on the concre- 
tions, but by producing a more copious secretion of urine. 



222 DIURETICS. 

DIGITALIS, U. S. P. 

Digitalis has very little, if any, influence on the renal epithe- 
lium ; it produces diuresis mainly through its stimulant action 
on the heart and blood-vessels. 

In the dropsy of heart disease it is preeminent as a diuretic 
when used in doses just sufficient to maintain the proper 
degree of tension in the renal blood-vessels. We must remem- 
ber, however, that by giving it too freely we may cause exces- 
sive constriction of the arterioles, and thereby defeat the object 
for which we have employed it. 

Various opinions are held as to the advisability of using 
digitalis to excite the secretory function of the kidneys in acute 
Bright s disease. In deciding this question a very important 
factor to be considered is the state of the circulation. We 
believe that when the pulse is strong, when the second sound 
of the heart at the aortic cartilage is accentuated, and when 
dropsy is absent or is slight, the drug should not be employed. 
On the other hand, when there are evidences of lowered 
arterial tension and when dropsy is marked, it is often of great 
service in reestablishing elimination through the kidneys. In 
chronic parenchymatous nephritis it may be used to increase the 
flow of urine and to reduce the dropsy, but, like all other 
diuretics, it is a very uncertain remedy. In chroyiic interstitial 
nephritis so long as the arterial tension is high and the urine 
is abundant, there is, of course, no indication for diuretics ; 
but late in the disease, when dilatation of the heart supervenes 
and occasions oliguria, dropsy, dyspnea, and a weak, irregular 
pulse, digitalis is our most reliable remedy. In dropsy of hepatic 
origin the drug may be combined with mercury, as in the well- 
known Niemeyer's pill (p. 5 2 )> but its action is often disappoint- 
ing. In serous effusions of an inflammatory character, such as are 
encountered in pleurisy and pericarditis, it is of doubtful utility. 

STROPHANTHUS, U. S. P. 

Strophanthus is a somewhat more active diuretic than 
digitalis, probably because it raises the blood-pressure without 
constricting the renal arteries. It is possible, too, that this 
drug has a very slight irritant action on the renal epithelium. 
It may be employed in the same class of cases in which 
digitalis has been recommended. 

CAFFEINA, U. S. P. 

(Caffein.) 

CafTein is a very powerful diuretic, acting for the most part, 
it is generally believed, directly on the renal epithelium. It 



THE OBR OMINA— THE CIN. 223 

increases the secretion of water to a greater extent than it 
does the output of solids, and, therefore, it lowers the specific 
gravity of the urine. After the ingestion of much sugar- 
forming food it sometimes gives rise to a slight glycosuria. 
It may be employed in any form of general dropsy except that 
of acute nephritis. In cardiac dropsy it not infrequently sur- 
passes digitalis in its power of producing diuresis, and a com- 
bination of digitalis and caffein may prove more effective than 
either drug singly. In chronic parenchymatous nephritis also 
caffein may succeed when digitalis has failed. Its tendency to 
cause insomnia must always be borne in mind. 

THEOBROMINA. 

(Theobromin.) 

Theobromin is an alkaloid closely related to caffein, and 
obtained from the seeds of Theobroma Cacao, or chocolate 
tree, extensively grown in South America and the West Indies. 
It occurs in minute whitish crystals, of a bitter taste, and spar- 
ingly soluble in water and alcohol. The dose is from 3-10 gr. 
(0.2-0.65 gm.). Owing to their ready solubility in water the 
double salts, theobromin-sodium and sodium acetate {agurin) 
and theobromin-sodium and sodium salicylate (diuretin), are 
preferred by some practitioners to the pure alkaloids. These 
compounds are decomposed on exposure and are incompatible 
with acids. Either salt may be given in doses of from 5 to 1 5 
gr. (0.3-1.0 gm.) in peppermint-water or in capsules. 

The action of theobromin resembles that of caffein, but it 
has much less influence than the latter on the brain and circu- 
latory system. It produces diuresis mainly through its in- 
fluence on the renal epithelium. It is eliminated in the urine 
partly unchanged and partly in the form of xanthin bodies, to 
which, like caffein, it is closely allied. 

Theobromin may be used as a diuretic in the same class of 
cases as caffein. On account of its inferior rank as a circula- 
tory stimulant it is not so generally useful as digitalis in the 
dropsy of cardiac origin, but it will be found an excellent 
adjuvant to that drug in some cases. In chronic nephritis, 
when degeneration of the kidneys is far advanced, like other 
diuretics, it often proves ineffectual in removing the dropsy. 

THEOCIN. 

(Theophyllin.) 

Theocin is a synthetic xanthin derivative, isomeric with 
theobromin (dimethyl xanthin). It is identical with theophyl- 



224 DIURETICS. 

lin, a natural alkaloid existing in small quantities in tea (Thea 
sinensis). The artificial product is a white crystalline sub- 
stance with a slightly bitter taste. It is soluble in about 200 
parts of water. 

Theocin is a powerful diuretic, but its effects are evanescent, 
rarely lasting more than four or five days. Like theobromin, 
it has little influence upon the circulation, but acts directly by 
stimulating the renal epithelium. It may be employed in 
dropsy from any cause, excepting that of acute nephritis. It is 
usually well borne, but untoward effects, such as nausea and 
vomiting, headache and vertigo, are not uncommon. To 
secure the best results its administration should be followed 
after a few days by that of digitalis or an alkaline diuretic. The 
dose of theocin is from 5-8 gr. (0.3-0.5 gm.) in hot liquid, 
after meals. 

CONVALLARIA, U. S. P. 

The action of convallaria resembles that of digitalis. While 
it has advantages in not having any cumulative effect and in 
not disturbing the stomach, it is distinctly inferior to digitalis 
both as a circulatory stimulant and as a diuretic. It occasion- 
ally succeeds, however, in cases of cwdiac dropsy in which 
digitalis has been tried without avail. 

SCILLA, U. S. P. 

(Squill.) 

Squill is the bulb of the Urginea maritima, a perennial herb 
growing on the shores of the Mediterranean Sea. According 
to Merck, it contains three active constituents, scillitin, scilli- 
toxin (scillain), and scillin. No principle, however, that has 
yet been isolated represents fully the properties of the crude 
drug. The dose of powdered squill is from 1-3 gr. (0.065- 

0.2 gm.). 

Preparations. Dose. 

Acetum Scillsg, U. S. P 10-30 min. 

Fluidextractum Scillae, U. S. P 1-3 min. (0.06-0.2 c.c). 

Tinctura Scillse, U. S. P . 5-20 min. (0.3-1.2 c.c). 

Syrupus Scillae, U. S. P i-l fl. dr. (2.0-4.0 c.c). 

Syrupus Scillae Compositus, U. S. P. (fl. ext. of 

squill, 8 per cent. ; fl. ext. of senega, 8 

per cent. ; tartar emetic, 0.2 per cent.) . . 10-60 min. (0.6-4.0 c.c). 

Physiologic Action and Therapeutics. — Squill has an 
influence on the circulation very similar to that of digitalis. 
It also produces diuresis, partly by increasing the quantity of 
blood flowing through the kidneys, and partly, there is reason 



SCOPARIUS—APOCYNUM. 225 

to believe, by directly stimulating the renal epithelium. Large 
doses cause vomiting and purging, and, in addition, if much of 
the drug be absorbed, albuminuria and hematuria. 

Squill is employed chiefly as a stimulating expectorant (see 
p. 288) and as a diuretic. For the latter purpose it is rarely 
given by itself, but in combination with digitalis. Reference 
has already been made to the value of a combination of digi- 
talis, squill, and blue-mass in some cases of cardiac and hepatic 
dropsy. It is contraindicated in acute nephritis. As a diuretic 
it is usually prescribed in substance and in pill form. 

SCOPARIUS, U. S. P. 

(Broom.) 

Scoparius is the tops of Cytisus Scoparius, a shrub indigenous 
to Western Asia and Southern Europe, and cultivated in the 
United States. It contains a liquid alkaloid, spartein, and a 
neutral principle, scoparin. The salts of spartein, of which the 
sulphate is official, are crystalline solids. Scoparin is rarely 
used; its dose by the mouth is from 5-15 gr. (0.3-1.0 gm.). 

Preparations. Dose. 

Fluidextractum Scoparii £-1 fl. dr. (2.0-4.0 c.c). 

Decoctum Scoparii (1 oz.-l pint — 30.0 gm.- 

0.5 L.) 1-3 fl. oz. (30.0-90.0 c.c). 

Physiologic Action and Therapeutics. — The chief 
effect of moderate doses of scoparius is an increase in the flow 
of urine. The diuresis is not due to the spartein, which has an 
action similar to that of coniin (see p. 151), but to the scoparin, 
which probably acts directly on the kidney. Large doses cause 
vomiting and purging. Scoparius, alone or with digitalis, is 
sometimes efficacious in cardiac dropsy. The decoction is gen- 
erally employed. 

APOCYNUM, U. S. P. 

(Canadian Hemp.) 

Apocynum is the root of Apocynum cannabinum, a perennial 
plant growing in North America, from Canada to Florida. In 
addition to tannin and a bitter extractive, it contains an indif- 
ferent resinous principle, apocynin, and an active glucosid, 
apocynein. 

Preparation. Dose. 

Fluidextractum Apocyni, U. S. P 5-10 min. (0.3-0.6 c.c). 

Physiologic Action and Therapeutics. — Apocynum, 
through its glucosid, apocynein, has an action on the circula- 

15 



226 DIURETICS. 

tion resembling that of digitalis. Like the latter, also, it in- 
creases the flow of urine. In large doses it is an active irritant 
to the gastro-intestinal tract, causing severe vomiting and 
purging. Apocynum has been used as a diuretic in cardiac 
and renal dropsy \ but it is unreliable and prone to disturb the 
stomach. 

VEGETABLE SALTS OF POTASSIUM. 

Physiologic Action. — In very large doses potassium is 
a depressant to both the nervous system and the circulatory 
system, especially to the latter. In the case of the vegetable 
salts of potassium, however, the action of the base is subordi- 
nate to that of the acid radical, and a depressant effect is never 
observed except after a very large dose of the salt or after its 
prolonged administration. The chief effect of a moderate dose 
of any one of the vegetable salts of potassium is an increased 
secretion of urine. The mineral salts of the urine, both of 
potassium and sodium, are increased, but the evidence is not 
convincing that the salts of potassium hasten oxidation in the 
tissues, and in consequence augment nitrogenous elimination. 
In large doses they impart an alkaline reaction to the urine. 
The claim made by some authorities that they increase the 
secretion of bile has not been substantiated by recent inves- 
tigations. 

Therapeutics. — It is an established fact that acute rheu- 
matism is favorably influenced by the administration of the 
vegetable salts of potassium, but until we have a clearer 
understanding of the nature of this disease it would be use- 
less to speculate upon the modus operandi of the remedies 
employed in its treatment. Thirty grains (2.0 gm.) of the 
alkali should be given every three or four hours until the 
urine becomes neutral or slightly alkaline. Excellent results 
are often obtained by combining an alkaline salt with a salicylic 
compound. 

Alkalis in copious drafts of water are efficient adjuvants 
to colchicum in the treatment of gout ; but it is not known 
whether they act by hindering the formation of uric acid, by 
promoting the solution of uric acid compounds, or simply by 
benefiting gastric catarrh, relieving constipation, and stimulat- 
ing the activity of the kidneys. 

Alkalis or mineral waters containing them are apparently 
of service in acute catarrh of the bile-ducts and in cholelithiasis, 
probably by relieving coexisting duodenal catarrh, and not by 
exerting any direct influence on the bile itself or its concretions. 



VEGETABLE SALTS OF POTASSLUM. 227 

They are also useful in relieving dysuria that is due to excessive 
acidity of the urine, and through their diluent action they tend 
to mitigate the suffering occasioned by uric acid gravel and 
uric acid calculi. In acute Bright s disease they serve to main- 
tain the excretion through the kidneys and to render the urine 
less irritating. 

Finally, the vegetable salts of potassium are efficient sedative 
expectorants in the beginning of acute bronchitis, especially 
when the secretion is viscid and scanty. 

Incompatibles. — The vegetable salts of potassium are in- 
compatible with acids, mineral salts, and alkaloidal salts. 

POTASSII BICARBONAS, U. S. P. 

(Potassium Bicarbonate ; KHC0 3 .) 

Potassium bicarbonate occurs in colorless prismatic crystals, 
odorless, and of a saline, alkaline taste. It is soluble in 3 
parts of water, and almost insoluble in alcohol. The dose is 
from 10-30 gr. (0.65-2.0 gm.) in solution well diluted. On 
account of its unpleasant taste it is less frequently prescribed 
than the citrate and acetate of potassium. Potassium bicar- 
bonate is used in making the following preparations : 

Liquor potassii arsenitis (Fowler's solution), U. S. P. 
Liquor potassii citratis, U. S. P. 
Liquor magnesii citratis, U. S. P. 

POTASSII CARBONAS, U. S. P. 

(Potassium Carbonate; K 2 C0 3 .) 

Potassium carbonate is a white, granular, deliquescent pow- 
der, alkaline in reaction, and caustic to the taste. It is freely 
soluble in water, but insoluble in alcohol. The dose is from 
10-30 gr. (0.65-2.0 gm.), but on account of its irritant proper- 
ties it is rarely used internally. From potassium carbonate the 
following preparations are made : 

Mistura ferri composita, U. S. P. 

Pilulse ferri carbonatis (Blaud's Pills), U. S. P. 

POTASSII BITARTRAS, U. S. P. 

(Potassium Bitartrate ; Cream of Tartar ; KHC 4 H 4 6 .) 

Potassium bitartrate occurs in colorless or slightly opaque, 
rhombic crystals, or as a white powder, odorless, and of an 
acidulous taste. It is soluble in about 200 parts of water, and 
very sparingly soluble in alcohol. The dose is from 1 5-60 gr. 



228 DIURETICS. 

(1.O-4.O gm.). Unlike the other vegetable salts of potassium, 
the bitartrate resists oxidation in the body, and, therefore, much 
of it is eliminated unchanged. As it is not readily absorbed 
from the alimentary canal, it is also an aperient. The double 
tartrate of potassium and sodium (Rochelle salt) is formed by 
adding potassium bitartrate to a hot solution of sodium car- 
bonate, 

Preparation. Dose. 

Pulvis Jalapae Compositus, U. S. P. (jalap, 35 ; 

potassium bitartrate, 65) 15-60 gr. (1.0-4.0 gm.). 

POTASSII ACETAS, U. S. P. 

(Potassium Acetate ; KC 2 H 3 2 .) 

Potassium acetate occurs as a white powder or as crystal- 
line masses, very deliquescent, odorless, and of a saline taste. 
It is soluble in 0.4 part of water and in 2 parts of alcohol. 
The dose is from 15-60 gr. (1.0-4.0 gm.). On account of its 
ready solubility, pleasant taste, and freedom from irritant 
properties, potassium acetate is a favorite alkaline diuretic. 

POTASSII CITRAS, U. S. P. 

(Potassium Citrate; K 8 C 6 H 5 O t + H 2 0.) 

Potassium citrate occurs in transparent, prismatic crystals or 
white, granular powder, deliquescent on exposure to air, odor- 
less, and having a pleasant saline taste. It is soluble in 0.5 
part of water, but sparingly soluble in alcohol. The dose is 
from 15-60 gr. (1.0-4.0 gm.). 

Preparations. Dose. 

Liquor Potassii Citratis, U. S. P. (neutral 

mixture) \-i fl. oz. (15.0-30.0 c.c). 

Potassii Citras Effervescens, U. S. P. . . . 30-90 gr. (2.0-6.0 gm.). 

The citrate of potassium has properties closely resembling 
those of acetate of potassium, and the two salts may be used 
interchangeably. The solution of potassium citrate is used in 
mild febrile conditions to promote the secretion of the skin and 
kidneys. 

POTASSII NITRAS, U. S. P. 

(Potassium Nitrate ; Saltpeter; KN0 8 .) 

Potassium nitrate occurs as colorless, transparent, rhombic 
prisms, or as a crystalline powder having a cooling, saline taste. 
It is permanent in the air. It is soluble in 3.6 parts of water, 
and sparingly soluble in alcohol. The dose is from 5-20 gr. 
(0.3-1.3 gm.), in solution, well diluted. 



POTASSII CHLORAS. 229 

Physiologic Action.— Beyond being more irritating to the 
stomach, the effect of potassium nitrate in moderate doses is 
not materially different from that of the vegetable salts of 
potassium. Like the latter, it increases the flow of urine 
through its direct action on the secreting cells of the kidneys. 
In large doses potassium nitrate is not only more irritating 
than the vegetable salts, but, owing to the relatively greater 
influence of the metallic base, — potassium, — it is distinctly 
more depressing to the heart and nervous system. The drug 
is partly eliminated in the urine and saliva unchanged ; a 
greater part undergoes reduction in the tissues, but its educts 
are at present unknown. 

Toxicology. — Toxic doses produce the symptoms of acute 
gastro-enteritis, profound muscular weakness, and collapse. 
In some instances diuresis is replaced by oliguria or anuria. 

Therapeutics. — Potassium nitrate may be employed as a 
diuretic in general dropsy, but its utility is no greater than that 
of the acetate or bitartrate of potassium, which are less irri- 
tating to the gastro-intestinal tract. Inhalation of the smoke 
of burning niter paper is sometimes effective in asthma. 

POTASSII CHLORAS, U. S. P. 

(Potassium Chlorate ; KC10 3 .) 

Potassium chlorate occurs in the form of colorless, crystal- 
line plates, odorless, and of a cooling saline taste. It is sol- 
uble in 16 parts of water, and sparingly soluble in dilute 
alcohol. The dose is from 3-10 gr. (0.2-0.65 gm.), in solu- 
tion, well diluted. 

Preparation. Dose. 

Trochisci Potassii Chloratis, U. S. P. (each contains about 
2^ gr. — 0.15 gm.) 1-4 troches. 

Physiologic Action. — When applied in dilute form to 
mucous membranes, potassium chlorate produces a stimulating 
and alterative effect ; in concentrated form it is a decided irri- 
tant. When taken internally it does not, as was formerly 
believed, yield its oxygen to the blood, but it passes out of 
the body unchanged. Most of it — more than 90 per cent. — 
escapes in the urine, but, according to Isambert, small quanti- 
ties can be recovered from the saliva, the tears, and the milk 
of nursing women. The only appreciable effect of moderate 
doses, well diluted, is an increase in the flow of urine. Con- 
centrated solutions, even of therapeutic doses, give rise to a 



230 DIURETICS. 

burning sensation in the stomach, followed by nausea and 
vomiting. Jacobi 1 was the first to point out that the practice 
of giving the drug internally in large doses was a dangerous 
one, and to prove that many deaths that had been attributed 
to other causes were in reality due to potassium chlorate 
poisoning. 

Toxicology. — The symptoms of potassium chlorate poi- 
soning are the resultant of the drug's action on the heart, 
digestive tract, kidneys, and blood. Through its basic radical 
it depresses the circulation, and through its acid radical it 
irritates the stomach, intestines, and kidneys, and also effects 
a peculiar change in the blood — namely, the conversion of 
hemoglobin into methemoglobin, a compound very tenacious 
of its oxygen. The first symptoms of poisoning are thirst 
and abdominal pain, followed by vomiting and purging. Cya- 
nosis is almost constantly present, and is accompanied by 
dyspnea and the usual phenomena of cardiac failure. The 
urine is scanty, dark colored, and albuminous, and on micro- 
scopic examination reveals numerous pigmented tube-casts 
and granular detritus derived from the red blood-cells. Jaun- 
dice is often present, and in many cases death is preceded by 
coma and convulsions. The immediate cause of death may 
be heart failure, asphyxia, or uremia, according as the action 
of the poison has been most pronounced on the circulation, 
blood, or kidneys. Apart from gastro-enteritis and nephritis, 
the most striking postmortem change is that which involves 
the blood. The color of the blood is changed to a chocolate 
hue, oxyhemoglobin is replaced by methemoglobin, and many 
of the red cells are decolorized and more or less disintegrated. 
The organs generally may be chocolate colored from the 
accumulation in the tissues of liberated blood-pigment. In 
the recorded cases the minimum fatal dose for an adult has 
been 4 drams ; for a child of four years, 3 drams ; and for an 
infant, I dram. 

The treatment of poisoning consists in evacuating the stomach 
and in administering demulcents and diluents. Subcutaneous 
injections of normal salt solution may be tried. 

Therapeutics. — Potassium chlorate makes an excellent 
local application in inflammatory affections of the mouth and 
throat. Thus, it is valuable in the various forms of stomatitis 
and in acute pharyngitis. In these affections a solution of 
from 10-20 gr. (0.65-1.3 gm.) to the ounce (30.0 c.c.) may be 
used as a wash or gargle. In acute pharyngitis tannic acid or some 
preparation containing it is frequently added to the solution. 

1 Medical Times, April, 1861. 



LITHII CARBONAS. 23 I 

In scarlatina and diphtheria it is generally advisable to avoid 
solutions of potassium chlorate, and to select an agent that, if 
swallowed, will not contribute to the existent renal irritation. 
In ulcerous stomatitis this salt is almost a specific, and may be 
used internally as well as locally. The dose for a child of three 
years is from 2-3 gr. (0.13-0.2 gm.), well diluted, every three 
hours. Benefit from its internal administration is to be attrib- 
uted to its continuous elimination in the saliva. Tincture of 
ferric chlorid may be used as an adjuvant, as in the following 
formula : 

&. Potassii chloratis, gr. xl (2.6 gm.) ; 

Tincturae ferri chloridi, tt\xxxij (2.0 c.c.) ; 

Syrupi zingiberis, fgvj (22.5 c.c.) ; 

Aquae, q. s. ad f^ij (60.0 c.c). — M. 

Sig. A teaspoonful in water every three hours. 

It is generally believed that salivation is less likely to result 
from the continuous use of mercury when a solution of potas- 
sium chlorate is used at the same time as a mouth-wash. In 
some cases of syphilis troches of the salt are useful as preven- 
tives of both mercurial stomatitis and of mucous patches. 

Incompatibles. — Owing to rapid oxidation or reduction 
violent explosion may occur when potassium chlorate is 
triturated with such substances as tannic acid, phosphorus, 
pulverized charcoal, sulphur, sulphids, sugar, hyposulphites, 
hypophosphites, and ammonium chlorid. Mixtures of potas- 
sium chlorate, tincture of ferric chlorid, and glycerin, when 
warm, are liable to explode. The salt reacts with strong 
hydrochloric acid, setting free chlorin gas ; with potassium 
iodid it may form the exceedingly irritant potassium iodate, 
and from syrup of ferrous iodid it may precipitate free iodin. 

LITHII CARBONAS, U. S. P. 

(Lithium Carbonate ; Li 2 C0 3 .) 

Lithium carbonate occurs as a white powder, odorless, and 
of an alkaline taste. It is soluble in 75 parts of water and 
insoluble in alcohol. Its dose is from 5-20 gr. (0.3-1.3 gm.). 

Physiologic Action and Therapeutics. — The effect of 
the vegetable salts of lithium is very similar to that of the 
corresponding salts of potassium ; like the latter, they increase 
the quantity of urine and lessen its acidity. Lithium salts were 
originally recommended in the treatment of gout and the uric 
acid diathesis because it was found that outside of the body 
lithium united with uric acid to form a more soluble salt than 



232 OTHER DIURETICS. 

did either sodium or potassium ; but as it has been clearly dem- 
onstrated that alkaline medication is without influence on the 
urates present in the blood or tissues, it is very doubtful 
whether the salts of lithium are any more potent in these 
diseases than the vegetable salts of potassium. The natural 
mineral waters are extensively employed in the treatment of 
gout and nephrolithiasis, but any efficacy that they may pos- 
sess is probably dependent upon the depurant action of the 
water itself and not upon the small amount of salt they 
contain. 

LITHII CITRAS, U. S. P. 

(Lithium Citrate ; Li 3 C 6 H 5 7 -f 4.H 2 0.) 

Lithium citrate is a white, deliquescent powder, odorless, 
and of a cooling, alkaline taste. It is soluble in two parts of 
water and insoluble in alcohol. Its dose is from 5-20 gr. 
(0.3-1.5 gm.). 

Preparation. Dose. 

Lithii Citras Effervescens, U. S. P 1-2 dr. (4.0-8.0 gm.). 

Lithium citrate is the therapeutic equivalent of lithium car- 
bonate, and may be substituted for the latter when a solution 
is preferred to a powder. 

LITHII BENZOAS, U. S. P. 

(Lithium Benzoate; LiC 7 H 5 2 .) 

Lithium benzoate occurs in the form of a white powder or 
small shining scales, permanent in the air, odorless, and of 
cooling, sweetish taste. The dose is from 5-30 gr. (0.3-2.0 
gm.). 

This drug was recommended in the treatment of gout on 
the ground that it would prove especially active as a uric acid 
solvent, the acid radical uniting with proteid derivatives to 
form the soluble hippuric acid, and the basic radical uniting 
with free uric acid to form a readily soluble urate. This rea- 
soning, however, has been shown to be fallacious by recent 
studies on uric acid formation and elimination, and, moreover, in 
practice, lithium benzoate has been found to be less efficacious 
in gouty conditions than the other salts of lithium. 

OTHER DIURETICS* 

Calomel (see p. 330). — Several theories have been advanced 
to explain the diuretic action of this drug ; the most tenable 
one is that it acts directly on the renal epithelium. It is espe- 
cially useful in the dropsy of cardiac disease, but it is not with- 



STIMULANTS TO THE GENITO-URINARY TRACT. 233 

out value in serous effusions of hepatic or renal origin. A few 
large doses (2-3 gr. — 0.13-0.2 gm.) may be given, opium being 
added, when necessary, to prevent purging ; or small doses (f 
gr. — 0.016 gm.) may be employed as adjuvants to digitalis 
and squill. 

_ Spirit of Nitrous Ether (see p. 262).— Sweet spirit of 
niter is an agreeable remedy of feeble diuretic power. Each 
of its components — ethyl nitrite, ether, and alcohol — probably 
contributes to its activity. It is useless in general dropsy, but 
it is very efficacious in relieving oliguria that is due to febrile 
disease or active congestion of the kidneys. The usual dose 
as a diuretic is from 1-2 fl. dr. (4.0-8.0 c.c). 

Incompatible s. — Spirit of nitrous ether is incompatible with 
antipyrin, iodids, ferric sulphate, tincture of guaiacum, muci- 
lage of acacia, and tannic acid. 



STIMULANTS TO THE GENITO-URINARY 

TRACT. 

Under this heading will be considered those drugs that 
stimulate the mucous membrane of the whole genito-urinary 
tract. All these act also upon the secretory cells of the kid- 
neys, and increase more or less the quantity of urine, but this 
influence is subordinate to that exerted upon the mucous mem- 
branes over which the urine flows. Many of them contain 
antiseptic principles that are eliminated by the kidneys, and 
that are powerful enough to inhibit the growth of bacteria and 
to prevent decomposition of the urine. In large doses these 
drugs are capable of producing acute inflammation of the 
bladder and urethra, and even of the kidneys themselves. 
The most important members of this group are : 

Copaiba. Oil of erigeron. 

Cubeb. Buchu. 

Matico. Uva ursi. 

Oil of sandalwood. Chimaphila. 

Turpentine. Pareira. 

Juniper. Cantharides. 

The combined stimulant and antiseptic properties of these 
drugs make them useful remedies in subacute and chronic 
pyelitis, cystitis, and urethritis. They are contraindicated when 
the inflammation is of an acute character. 



234 STIMULANTS TO THE GENITO-URINARY TRACT. 
COPAIBA, U. S. P. 

(Balsam of Copaiba; Copaiva.) 

Copaiba is the oleoresin of Copaiba Langsdorffi and other 
species of Copaiba, a small tree growing in the northern 
states of South America. It is a yellowish or brownish 
viscid liquid, having a peculiar, aromatie odor and a bitter, 
acrid taste. It contains a volatile oil (40.9 per cent.), resins, 
a bitter principle, and copaivic acid. The dose of copaiba is 
from 5-30 min. (0.3-2.0 c.c.) in capsule or emulsion. 

Preparation. Dose. 

Oleum Copaibae, U. S. P 5-15 min. (0.3-1.0 c.c). 

Physiologic Action and Therapeutics. — In therapeu- 
tic doses copaiba acts as a stimulant to mucous membranes. 
As its active principles are eliminated chiefly by the kid- 
neys and lungs, it particularly influences the mucous mem- 
brane of the genito-urinary tract and bronchi. The drug also 
excites diuresis, and imparts to the urine decided antiseptic 
properties. The resins and most of the oil are excreted by 
the kidneys, but a part of the oil escapes through the lungs 
and skin. The oil appears in the urine in part unchanged, and 
in part in combination with glycuronic acid. Urine contain- 
ing the resins of copaiba responds to the nitric acid test for 
albumin, but the resinous precipitate can be distinguished by 
its rapid disappearance on the addition of alcohol. Fehling's 
solution may also be reduced by urine containing the educts 
of copaiba. In large doses copaiba acts as an irritant, causing 
burning in the stomach, vomiting and purging, lumbar pains, 
frequent micturition, and even strangury. In some persons the 
administration of the drug is followed by an eruption on the 
skin, urticarial, scarlatinoid, or morbilliform in type. 

In inflammatory diseases of the genito-urinary tract, such as 
pyelitis, cystitis, and urethritis, copaiba is a useful remedy; it 
should not be used, however, until the most acute symptoms 
have subsided. In gonorrhea, after the discharge has become 
well established, the drug affords considerable relief and tends 
to prevent complications. It may be combined advantageously 
with other drugs, like cubeb and salol, which tend to render the 
urine sterile. As a simple diuretic it has been well recommended 
in dropsy due to cirrhosis of the liver. In subacute and chronic 
bronchitis with profuse purulent expectoration it is sometimes 
beneficial, but generally it is less useful than oil of eucalyptus 



CUB EB A— MA TICO. 235 

or the preparations of guaiacol. Copaiba has a long-standing 
reputation as a stimulant application for indolent ulcers. 

Both copaiba itself and the oil are eligible preparations. On 
account of their unpleasant taste they should always be pre- 
scribed in capsules or as an emulsion. 

CUBEBA, U. S. P. 

(Cubeb.) 

Cubeb is the unripe fruit of Piper Cubeba, a perennial climber 
indigenous to Borneo and the neighboring islands. It contains 
a volatile oil (5-15 per cent), a resin, cubebic acid, and cubebin, 
which is inert. The dose of powdered cubeb is from \-2 dr. 
(2.0-8.0 gm.). 

Preparations. Dose. 

Fluidextractum Cubebae, U. S. P 10-30 min. (0.6-2.0 c.c). 

Oleoresina Cubebae, U. S. P 5-15 min. (0.3-1.0 c.c). 

Oleum Cubebae, U. S. P 5-15 min. (0.3-1.0 c.c). 

Trochisci Cubebae, U. S. P. (each, contains 

about \ gr. (0.02 gm.) of oleoresin) . . . 1-5 troches. 

Physiologic Action and Therapeutics. — Cubeb pos- 
sesses properties closely resembling those of copaiba ; hence 
it may be employed to meet the same indications as the latter. 
A combination of the two is often more effective than either 
alone. Cubeb is somewhat less liable than copaiba to disturb 
digestion or to cause cutaneous rashes. Troches of cubeb are 
useful in relieving hoarseness and fatigue of the larynx result- 
ing from prolonged use of the voice. The oleoresin is the 
most active preparation ; it should be given in capsules or as 
an emulsion. 

MATICO, U. S. P. 

Matico is the leaves of Piper angustifolium, a shrub growing 
in Mexico and South America. It contains a volatile oil, a 
resin, tannin, and artanthic acid. 

Preparation. Dose. 

Fluidextractum Matico, U. S. P J-2 fl. dr. (2.0-8.0 c.c). 

Physiologic Action and Therapeutics. — Matico some- 
what resembles cubeb in its action, and has been given in the 
same class of cases. The leaves, on account of their hairy 
surfaces, favor coagulation and arrest bleeding when applied to 
small wounds. The drug is rarely employed at the present 
time. 



236 STIMULANTS TO THE GENITO-URINARY TRACT. 
OLEUM SANTALI, U. S. P. 

(Oil of Santal; Oil of Sandalwood.) 

Oil of santal is a volatile oil distilled from the wood of San- 
talum album, a small tree growing in India and the East Indian 
Islands. It is a thick, pale-yellow liquid, having a strong, aro- 
matic odor and a pungent, spicy taste. It is soluble in alcohol. 
The dose is from 5-20 min. (0.3-1.2 ex.), in capsules or as an 
emulsion. 

Oil of santal resembles copaiba in its action, but is less 
irritant. 

TEREBINTHINA, U. S. P. 

(Turpentine.) 

Turpentine is a concrete oleoresin obtained from Pinus palus- 
tris and other species of Pinus growing in the Southern United 
States, especially in North Carolina. When subjected to dis- 
tillation it yields a volatile oil, oleum terebinthince, and a solid 
residue, resin. 

OLEUM TEREBINTHINA, U. S. P. 

(Oil of Turpentine; Spirit of Turpentine.) 

Oil of turpentine is a limpid, colorless, highly inflammable 
liquid, having a characteristic odor and taste. It contains sev- 
eral terpene hydrocarbons. The rectified oil is made by dis- 
tilling the ordinary oil with lime-water, and is the preparation 
always selected for internal use. 

Preparations. Dose. 

Oleum Terebinthinse Rectificatum, U. S. P. . 5-20 rain. (0.3- 1. 2 c.c). 
Emulsum Olei Terebinthinse, U. S. P. (15 

percent.) j-2 fl. dr. (2.0-8.0 c.c). 

Linimentum Terebinthinae, U. S. P. ( oil of turpentine, 35 ; resin cerate, 65 ) . 
Terpin hydrate (see p. 289) is a crystalline compound obtained by the inter- 
action of oil of turpentine, alcohol, and nitric acid. 

Terebene (see p. 288) is a liquid hydrocarbon made by oxidizing oil of turpen- 
tine with strong sulphuric acid. 

Physiologic Action. — When applied to the skin, oil of 
turpentine acts as an irritant, producing redness and burning, 
and, if the contact be prolonged, vesication. The drug has 
decided antiseptic properties, and is capable, even in dilute 
form, of preventing fermentation and putrefaction. Internally, 
in full doses, it causes a sense of warmth in the stomach, quick- 
ened respiration, and an increase in the rate and tension of the 
pulse. It escapes from the body through the respiratory tract 
and the kidneys, and imparts to the urine an agreeable odor 



TEREBINTHINM. 237 

resembling that of violets. In overdoses it produces abdom- 
inal pain, nausea, vomiting, embarrassed respiration, a rapid, 
feeble pulse, great muscular relaxation, lumbar pains, dysuria, 
scanty bloody urine, delirium, and finally coma. 

In therapeutic doses oil of turpentine acts as a circulatory 
stimulant and diuretic. In the alimentary canal it plays the 
part of a carminative and an antiseptic. On leaving the body 
it imparts its peculiar stimulant and antiseptic properties to the 
urine and the secretions of the respiratory tract. In suscepti- 
ble persons an erythematous or papular eruption may result 
from either its internal or its external use. 

Therapeutics. — Externally oil of turpentine is used as a 
rubefacient in various inflammatory affections, such as bro?ichi- 
tis, pleurisy, pneumonia, gastritis, and enteritis. It is best applied 
in these cases in the form of a stupe made by sprinkling freely 
with the oil a piece of flannel which has first been soaked in 
boiling water and then wrung dry. It may be allowed to 
remain on the affected part from ten to twenty minutes, 
according to the sensitiveness of the skin. Turpentine lini- 
ment makes an excellent application in muscular rheumatism 
and chilblains. 

Oil of turpentine is a reliable carminative, and may be ad- 
ministered either by the mouth or by the rectum. Trouble- 
some tympanites will often yield to the application of a stupe 
to the abdomen and the rectal injection of a pint of soapy 
water containing a tablespoonful of the oil. 

The oil is a valuable adjunct to alcohol in certain cases of 
typhoid fever. It is useful when the tongue is dry, brown, and 
fissured ; when there is a tendency to muttering delirium ; and 
when there is marked abdominal distention. It sometimes acts 
favorably as a stimulant and antiseptic in subacute and chronic 
inflammations of the genito- urinary tract, such as cystitis and 
urethritis. It may be employed as an expectorant in subacute 
and chronic brojichitis, when the expectoration is copious and 
purulent, but generally terebene will be found more agreeable. 
With some practitioners it has acquired a reputation as a hemo- 
static in passive hemorrhage from the stomach, intestines, lungs, 
or kidneys. Some cases of purpura hemorrhagica are favorably 
influenced by the oil. 

Oil of turpentine, J— I fl. oz. (15.0-30.0 c.c), with castor oil, 
has been used as an anthelmintic to destroy tape-worm, but 
there are other remedies equally effective and decidedly less 
dangerous. 

A mixture of 3 parts of oil of turpentine and 2 of ether, on 



238 STIMULANTS TO THE GENITO-URINARY TRACT 

the recommendation of Durande, of Dijon, was at one time 
largely employed as a solvent of gall-stones, but it has been 
abandoned from the lack of evidence as to its efficacy. 

Oil of turpentine is a powerful deodorant. In the form of 
vapor it may be employed to overcome the fetid odor of the 
breath in bronchiectasis and gangrene of the lung. It is service- 
able for removing the odor from the hands after postmortem 
examinations. Madden has found it efficacious in destroying 
the offensive character of the discharges in cancer of the uterus. 
He recommends a douche composed of a tablespoonful each 
of the oil and magnesia to a quart of boiling water ; the mix- 
ture is to be cooled and thoroughly stirred before being used. 
The penetrating odor of iodoform is lost to a great extent in 
the presence of turpentine. 

Whatever may have been the merits of old preparations of 
the oil in phosphorus-poisoning ; it is certain that the present 
article of commerce is entirely without efficacy. 

Contraindications. — It should not be prescribed when 
there is acute inflammation of the stomach, intestines, or 
genito-urinary tract. 

Administration. — Oil of turpentine may be administered 
on lumps of sugar, in capsules, or in emulsion. 

Incompatibles. — Bromin, iodin, nitric acid, and strong sul- 
phuric acid act with violence on oil of turpentine. 

RESINA, U. S. P. 

(Rosin ; Resin ; Colophony.) 

Rosin is the hard, transparent, amber-Colored residue left 
after distilling off the volatile oil from turpentine. 

Preparations. 

Ceratum Resinse, U. S. P. (rosin, 35 parts ; yellow wax, 15 parts; lard, 

50 parts). 
Ceratum Resinae Compositum, U. S. P. (rosin, 22.5 parts ; yellow wax, 

22.5 parts; suet, 30 parts; turpentine, 1 1.5 parts; linseed oil, 13. 5 

parts). 
Emplastrum Resinae (rosin, 14 parts; lead-plaster, 80 parts; yellow 

wax, 6 parts). 

Therapeutics. — Rosin cerate and compound rosin cerate 
are chiefly employed as stimulating applications for indolent 
ulcers. Rosin plaster is no longer official, rubber adhesive 
plaster {Emplastrum Adhcesivum) having been substituted for 
it. As it is less irritating to the skin, however, than the rubber 
adhesive plaster, it is to be preferred to the latter for strapping 



JUNIPER US— BUCHU. 239 

the chest in fracture of the ribs and in pleurisy, and for making 
compression over indolent leg-ulcers. 

JUNIPERUS. 

(Juniper.) 

Juniper is the fruit of Jtiniperus communis, an evergreen 
shrub growing in Northern Europe, Asia, and America. It 
contains a volatile oil, resin, and a non-crystalline principle, 
juniperin. 

Preparations. Dose. 

Oleum Juniperi, U. S. P 3-5 min. (0.2-0.3 ex.). 

Spiritus Juniperi, U. S. P. (5 per cent, of oil of 

juniper) ^-1 fl. dr. (2.0-4.0 c.c). 

Spiritus Juniperi Compositus, U. S. P. (equiv- 
alent to gin) . . 1-4 fl. dr. (4.0-15.0 c.c). 

Physiologic Action and Therapeutics. — Juniper is a 
more active diuretic than most of the stimulants to the genito- 
urinary tract. The compound spirit is useful in increasing the 
flow of urine in passive congestion of the kidneys resulting from 
chronic heart disease. Its combination with a vegetable salt 
of potassium enhances its effect. In subacute and chronic 
inflammatory diseases of the genito-urinary tract it is not 
generally so useful as copaiba, oil of santal, or buchu. 

OLEUM ERIGERONTIS, U. S. P. 

(Oil of Erigeron; Oil of Fleabane.) 

Oil of erigeron is a volatile oil distilled from the fresh, flower- 
ing herb of Erigeron canadensis, an annual shrub growing in 
waste places in North America. It is a pale-yellow liquid, 
having a persistent aromatic odor and taste. The dose is from 
5-15 min. (0.3-1.0 c.c), on sugar, in capsules, or as an emul- 
sion. 

Oil of erigeron resembles oil of turpentine in its action, but 
it is less powerful. It has been used to some extent as a sub- 
stitute for copaiba and oil of santal in the treatment of cystitis 
and gonorrhea. It has an established reputation as an internal 
hemostatic in hemorrhage from the uterus, lungs, intestines, and 
kidneys, especially when the bleeding is slight but persistent 

BUCHU, U. S. P. 

Buchu is the leaves of Barosma betulina, growing in South- 
ern Africa. Its active principle is a volatile oil, from which is 
derived barosma camphor or diosphenol. 



24O STIMULANTS TO THE GEN/TO- URINARY TRACT. 

Preparation. Dose. 

Fluidextractum Buchu, U. S. P £-1 fl. dr. (2.0-4.0 c.c. ). 

Physiologic Action and Therapeutics. — In therapeutic 
doses buchu acts as a stimulant to the mucous membrane of 
the genito-urinary tract. It is a feeble diuretic. The volatile 
oil is eliminated by the kidneys, and imparts to the urine an 
aromatic odor. Its presence also makes the urine more or 
less antiseptic. Overdoses may produce vomiting, purging, 
and strangury. 

Buchu is useful in the less severe forms of subacute and 
chronic cystitis. It is especially efficacious in chronic irritability 
of the bladder, manifested by frequent desire to urinate. In 
subacute cystitis it may be advantageously combined with an 
alkali, as in the following formula : 

R Fluidextracti buchu, fjvj (22.5 c.c); 

Potassii citratis, 5ss (15.0 c.c.) ; 

Spiritus getheris nitrosi, f§j (30.0 c.c); 

Syrupi limonis, fjij (60.0 c.c) ; 

Aquae, q. s. ad f^vj (180.0 c.c). — M. 

Sig. A tablespoonful in water every three hours. 

UVA URSI, U. S. P. 

(Bearberry. ) 

Uva ursi is the leaves of Arctostaphylos Uva-ursi, an ever- 
green shrub growing in the northern parts of Europe, Asia, 
and North America. It contains two glucosids, — arbutin and 
ericolin, — tannic acid, and an inert, resinous principle, urson. 
Its virtues depend very largely on arbutin, which appears as 
white, crystalline needles, of a bitter taste, and freely soluble 
in alcohol and hot water, but sparingly soluble in cold water. 
The dose of arbutin is from 2-5 gr. (0.13-0.3 gm.). 

Preparation. Dose. 

Fluidextractum Uvse Ursi, U. S. P \-2 fl. dr. (2.0-8.0 c.c). 

Physiologic Action and Therapeutics. — Uva ursi in 
therapeutic doses stimulates the mucous membrane of the 
genito-urinary tract, increases the activity of the kidneys, and 
renders the urine slightly antiseptic. It is excreted by the 
kidneys partly unchanged and partly as hydroquinon. Both 
uva ursi and arbutin may impart to the urine a dark-green 
color that is probably due to the presence of pigments derived 



CHIMAPHILA—CANTHARIS. 24I 

from the oxidation of hydroquinon. As uva ursi contains a 
considerable quantity (6-8 per cent.) of tannic acid, it has well- 
marked astringent properties. For the same reason its prepa- 
rations are incompatible with spirit of nitrous ether. Uva ursi 
may be employed to meet the same indications as buchu, but it 
is generally less efficient. 



CHIMAPHILA, U. S. P. 

(Pipsissewa.) 

Chimaphila is the leaves of Chimaphila umbellata, a peren- 
nial indigenous to North America, Northern Europe, and 
Northern Asia. It contains tannic acid, arbutin, ericolin, 
urson, and a neutral, crystalline principle, chimaphiiin. 

Preparation. Dose. 

Fluidextractum Chimaphilse, U. S. P. . . . \-l fl. dr (2.0-4.O ex.), 

Chimaphila has the same action and uses as uva ursi. 



PAREIRA, U. S. P. 

(Pareira Brava.) 

Pareira is the root of Chondrodendron tomentosum, a climb- 
ing tree growing in Brazil and Peru. It contains tannic acid 
and an alkaloid, buxin. 

Preparation. Dose. 

Fluidextractum Pareirse, U. S. P \-2. fl. dr. (2.0-8.0 c.c). 

Pareira has been used in the same class of cases as buchu. 



CANTHARIS, U. S. P. 

(Cantharides ; Spanish Flies.) 

Cantharides (see p. 440) in moderate doses is an active stim- 
ulant to the mucous membrane of the genito-urinary tract. In 
large doses it is a powerful irritant, causing intense abdominal 
pain, vomiting and purging, frequent micturition, dysuria, pria- 
pism, and scanty, albuminous, and at times bloody urine. The 
tincture, in doses of from 1-3 min. (0.06-0.2 c.c), has been used 
with advantage in certain cases of chronic parenchymatous ne- 
phritis. The greatest caution, however, must be exercised in 
le 



242 SEDATIVES TO THE GENITO-URINARY TRACT. 

in its administration, since if there be any remnant of an active 
inflammatory process, or if the drug be used too freely, serious 
harm may ensue. Henderson claims to have used cantharides 
successfully in a case of persistent hematuria, in which other 
remedies had been tried without avail. The drug has also been 
recommended in chronic pyelitis, cystitis, and urethritis. 



SEDATIVES TO THE GENITO-URINARY 
TRACT. 

Certain drugs play indirectly the part of sedatives to the 
genito-urinary tract by removing the causes of irritation. 
Thus, the alkaline diuretics afford relief from dysuria and 
frequent micturition, when these symptoms are due to ex- 
cessive acidity of the urine. Mineral waters, through their 
diluent action, soothe the mucous membrane when uric-acid 
calculi are present. Again, boric acid, salol, and urotropin, 
through their antiseptic and acidifying properties, subdue the 
distressing symptoms resulting from ammoniacal fermentation 
of the urine. But apart from these drugs, which allay irrita- 
tion by changing the character of the urine, there are others 
which exert a direct sedative influence on the urinary passages 
themselves. In this class are belladonna (see p. 75), hyoscy- 
amus (see p. 8 1), and perhaps zea. These remedies may be 
employed for their sedative effect when there is acute inflam- 
mation or excessive irritability of the bladder or urethra. 

ZEA, U. S. P. 

(Corn-silk.) 

Zea is the styles and stigmas of Zea Mays, or Indian corn. 
Its active constituents are a resin and maizenic acid. 

Preparations. Dose. 

Fluidextractum Zeae -|— 2 fl. dr. (2.0-8.0 c.c). 

Decoctum Zese (5 per cent.) 1-2 fl. oz. (30.0-60.0 c.c). 

Physiologic Action and Therapeutics. — Corn-silk acts 
as a feeble diuretic and as a sedative to the mucous membrane 
of the genito-urinary tract. It is very useful in acute cystitis 
and in the various forms of vesical irritability. 



URIC- ACID SOLVENTS. 243 

URIC-ACID SOLVENTS. 

Under this heading will be considered certain drugs that are 
employed to prevent the precipitation of insoluble urates in the 
body, or to effect the solution of uratic concretions that have 
already been formed. The alkalis and the alkaline mineral 
waters were among the first agents to be used for these pur- 
poses. That these remedies are often beneficial in gout cannot 
be denied, but that they owe their efficacy to a solvent action 
is exceedingly doubtful. Uric acid does not, as was formerly 
supposed, exist as such in the blood or tissues, but is present 
in the blood chiefly as a soluble quadriurate, and in the tissues 
as a solid and stable biurate. The only way in which alkalis 
could affect the quadriurate in the blood would be by hinder- 
ing its conversion into the insoluble biurate, but there is suffi- 
cient experimental evidence to show that these remedies have 
no such retarding effect. Nor can it be assumed that their 
usefulness depends upon their influence on the alkalinity of 
the blood, for it has been shown by Klemperer, Magnus-Levy, 
and others that the alkalinity of the blood in gout is very little, 
if at all, diminished, and that, moreover, considerable variations 
in alkalinity are met with in health. 

We are able, by the administration of alkalies, to keep the 
uric acid in the urine from precipitating, and possibly to redis- 
solve uric-acid gravel. This is accomplished, according to von 
Noorden, even with a urine that is still weakly acid, by the 
removal of the monophosphate of sodium, which, in particular, 
renders the urine insolvent, the biphosphate of sodium remain- 
ing as an active solvent. There is, however, very little evidence 
to support the belief that uratic deposits in the tissues or well- 
formed calculi in the pelvis of the kidney or bladder can be 
redissolved by the administration of alkalis. Finally, it has 
not been proved that the constitutional symptoms of gout, 
which are so often ameliorated by alkaline medication, are due 
to the formation of uric acid; on the contrary, there is much tes- 
timony to substantiate the view that uric acid itself is not pecu- 
liarly toxic. Until we possess a more complete knowledge of 
the pathogenesis of gout, no adequate explanation of the favor- 
able action of the alkalis can be given. Doubtless much of 
the good that accrues to gouty patients from sojourns at 
watering-places is to be attributed to strict regimen, temperate 
living, agreeable exercise in the open air, and the liberal use 
of pure water, rather than to the specific action of any salts 
that may be contained in the waters. 

Knowing that benzoic acid was eliminated in the urine chiefly 



244 APHRODISIACS AND ANAPHRODISIACS. 

as the soluble hippuric acid, Ure assumed that the drug would 
be efficacious as a uric-acid solvent in gout and nephrolithiasis. 
In consequence, the acid itself and its salts have been repeat- 
edly recommended in these conditions. But the assumption is 
opposed to the results of more recent investigations, which have 
shown that the hippuric acid is formed in the kidney, and not 
in the blood, and, moreover, that its formation is not attended 
by a corresponding decrease in the excretion of uric acid. 

Piperazin, or diethylendiamin, has been highly recom- 
mended for its solvent effects in gout and nephrolithiasis, but 
in the experience of many observers it has proved to be en- 
tirely inert. It is prepared by the action of ammonia on ethyl- 
ene bromid or chlorid, and appears as colorless, acicular crys- 
tals, very hygroscopic, and freely soluble in water. Its dose is 
from 5-10 gr. (0.3-0.65 gm.), well diluted. The only appreciable 
effect of such doses is a moderate increase in the quantity of 
urine. The excretion of uric acid, even in the presence of 
gouty concretions, is not increased. Large doses may cause 
nausea, malaise, stupor, muscular weakness, tremors, and inco- 
ordination. Solutions of 1 or 2 per cent, in normal urine will 
readily dissolve fragments of uric acid calculi in the test-tube, 
but the amount of unoxidized piperazin appearing in the urine 
after ordinary doses have been administered by the mouth has 
been shown to be without solvent action. Gouty tophi have 
been removed by the local injections of the drug, but the treat- 
ment is said to be very painful. Lycetol, or dimethylpiperazin 
tartrate, and lysidin, made by the interaction of ethylendiamin 
hydrochlorid and sodium acetate, are claimed to be more pow- 
erful solvents of uric acid than piperazin. 

Tunnicliffe and Rosenheim believe that the tartrate of piper- 
idin, a derivative of piperin, in doses of 15 grains (1.0 gm.), is 
an excellent solvent of gouty concretions. Weiss, Frankel, 
Ewald, and others have recently advocated the use of quinic 
acid, in combination with lithium (urosin) or with piperazin 
(sidonal). According to Weiss, quinic acid decreases the 
amount of uric acid in the urine, hippuric acid appearing in 
its stead. 

APHRODISIACS AND ANAPHRODISIACS. 

Aphrodisiacs are agents which stimulate the sexual appe- 
tite and increase the virile power. Sexual impotence results 
from a variety of causes ; in consequence its treatment, to be 
successful, must vary accordingly. In one instance the symp- 
tom is due to diabetes, in another to locomotor ataxia, and in 



APHRODISIACS AND ANAPHRODISIACS. 245 

still another to neurasthenia. The last is by far the most 
common cause of acquired impotence, and its diverse etiology 
must be carefully considered in formulating any special line of 
treatment. General hygienic measures should never be neg- 
lected. Judicious physical exercise, fresh air, and careful 
feeding are necessary to improve the nutritive functions. 
Abstinence from all sexual excitement is absolutely essential. 
Iron and arsenic are indicated when there is anemia. Hydro- 
therapy, massage, and electricity are valuble adjuvants in the 
treatment. Electricity, locally applied, often proves especially 
effective. A large electrode — the positive — should be applied 
over the lumbar spine, while the negative electrode is applied 
over the spermatic cord or perineum. A current of from 5 to 
10 milliamperes is sufficient. Hirt has repeatedly seen good 
effects follow the introduction of a metal-tipped sound into the 
urethra as far as the fossa navicularis, while the positive pole 
(anode) is placed over the lumbar cord, the current at the 
negative pole being made and broken several times. In many 
instances the psychic element is the all-important factor, and 
when such is the case, treatment must be directed to the mind 
rather than to the body. Advice calculated to promote con- 
fidence, to give encouragement, and to distract the patient's 
thoughts from his infirmity will be the most effectual. 

The chief drugs for which special aphrodisiac action has 
been claimed are : 

Nux vomica. Cantharides. 

Phosphorus. Yohimbin. 

In certain cases of impotence nux vomica proves very useful, 
not only through its general tonic influence, but also through 
its stimulant action on the sexual centers of the spinal cord. 

Phosphorus is generally believed to possess the power of 
improving the nutrition of the central nervous system, and, in 
consequence, to be of value in the various manifestations of 
nervous exhaustion. Whether this be true or not, small doses 
of phosphorus are often beneficial in sexual neurasthenia. The 
drug may be prescribed as phosphorus in doses of from 1 ^ - 
3^5- gr. (0.00064.— 0.0013 gm.), or as phosphid of zinc, in doses 
of from ^-/ f Z x - (0.003-0.006 gm.). 

Cantharides in large doses, by irritating the bladder and 
urethra, sometimes induces sexual emotions and erections, 
but in doses that can be regarded as safe the drug is entirely 
without aphrodisiac influence. 

Yohimbin is an alkaloid or a mixture of alkaloids obtained 



246 APHRODISIACS AND ANAPHRODISIACS. 

from the bark of the Cameroon tree — johimbehe. According 
to Lowey, it stimulates the sexual appetite and produces a 
marked congestion of the testes. The dose is from ^ 2 - \ gr. 
(0.005-0.01 gm.). Berger and Eulenberg have employed it 
with asserted excellent results in sexual neurasthenia. Krav- 
koff, however, who has very recently made a careful study of 
yohimbin, finds that the congestion of the sexual organs is 
not due to any specific action of the drug, but to its general 
vasodilating effect, and that while it possesses no aphrodisiac 
influence, it is, in the doses recommended, distinctly toxic. 

Orchitic and ovarian extracts, when first introduced, enjoyed 
for a time the reputation of being aphrodisiacs. 

Anaphrodisiacs are drugs which allay sexual desires. The 
most important members of this group are : 

Hyoscin. Camphor. 

Bromids. Lupulin. 

Anaphrodisiacs are useful in satyriasis, nymphomania, sper- 
matorrhea, priapism, and chordee. Hyoscin and the bromids 
are the most reliable of all drugs for subduing morbid excita- 
bility of the genital organs. Camphor in itself is of little value, 
but the monobromated camphor is often efficacious. 

Spermatorrhea and impotence are not infrequently associated 
symptoms in neurasthenia, and when such is the case, an an- 
aphrodisiac, such as hyoscin, may be given at bedtime to over- 
come the irritable weakness of the sexual apparatus, while 
general roborant measures are employed to combat the nervous 
exhaustion. In some 'instances seminal incontinence is the 
result of a local cause, such as persistent constipation, hemor- 
rhoids, prostatic hypertrophy, phimosis, extreme sensibility of 
the prostatic urethra, or loading of the urine with crystals 
of uric acid or calcium oxalate. It is needless to say that 
under these circumstances the removal of the local irritation 
is of paramount importance. The local application of cold 
water, or even of ice, avoidance of stimulating food, sleeping 
on a hard mattress without too much covering, the adjustment 
of some mechanical device to prevent the patient from sleeping 
on his back, are measures calculated to lessen the sensibility 
of the genital organs. When the emissions occur toward 
morning and are excited by distention of the bladder, it is a 
good plan to have the patient form the habit of voiding his 
urine at 1 or 2 o'clock in the morning. 



EMMENAGOGUES. 247 



EMMENAGOGUES. 

Emmenagogues are remedies that promote the menstrual 
flow. They may act indirectly by removing the remote 
pathologic cause of amenorrhea, or they may act directly by 
stimulating the uterus itself. There are very few indications 
for the employment of direct emmenagogues. In a large class 
of cases the suppression of the menstrual flow is dependent 
upon some general cause which has resulted in constitutional 
enfeeblement ; thus it may be due to anemia, persistent consti- 
pation, tuberculosis, Bright's disease, extreme obesity, or myx- 
edema. In such cases treatment should be directed to the 
primary disease, there being rarely any indication to address 
remedies to the amenorrhea as such. In conjunction with 
measures calculated to improve the general nutrition iron will 
be found efficacious in chlorosis, purgatives, especially aloes, 
when there is obstinate constipation, and thyroid extract when 
myxedema is the primary factor. In some cases absence of 
menstruation is dependent upon a pronounced defect in the 
development of the genital organs or upon atresia of the 
genital passages. Under such circumstances, emmenagogues 
would, of course, be of no avail. Again, amenorrhea may be 
a symptom of uterine or ovarian disease, and when such is the 
case, it is manifestly improper to goad the affected organs with 
stimulating drugs. Occasionally suppression is associated with 
some psychic disturbance, such as grief, anxiety, or fear. In 
these cases restoration of the catamenia usually occurs after a 
time without recourse to special medication. Acute suppres- 
sion from exposure to cold should be treated by rest in bed, 
hot sitz-baths, hot drinks, and hot applications to the abdomen 
and genitals. Constipation should be relieved by a laxative 
dose of aloes, and febrile reaction controlled with such remedies 
as aconite or spirit of nitrous ether. 

The only indications for treating amenorrhea as such by the 
use of direct uterine stimulants are: (i) When the suppression 
itself is the cause of painful symptoms — that is, when there is 
a menstrual molimen without bloody discharge ; (2) when the 
menses do not return upon the restoration of the general health, 
as is sometimes the case in girls during the developmental 
period. 

The following drugs are the most important direct emmena- 
gogues : 



248 EM MEN A GOG UES. 



Salts of manganese. 

Apiol. 

Senecio. 

Cantharides. 


Myrrh. 
Pennyroyal, 
Tansy. 
Savine. 


Oxalic acid. 


Rue. 


Pulsatilla. 





In addition to these drugs, electricity, particularly faradism, 
locally applied, has been highly extolled as a direct uterine 
stimulant in amenorrhea dependent upon imperfect develop- 
ment of the internal genitals or upon atrophy caused by 
superinvolution. One pole should be applied over the sa- 
crum and the other above the pubes, or, better, within the 
uterine cavity. 

MANGANUM. 

(Manganese; Mn.) 

The finding of traces of manganese in the red-blood cells 
and other tissues led to the recommendation of its salts in the 
treatment of chlorosis and other forms of anemia, but in the 
judgment of competent observers the drug is valueless as a 
hematinic. Ringer was the first to recommend potassium per- 
manganate as an emmenagogue, and there is sufficient evidence 
at present fully to establish its worth in this respect. It prob- 
ably acts directly on the uterus, and not indirectly through any 
influence exerted on the blood. It is most efficacious when 
given a few days before the expected menstrual period. It 
should be prescribed in doses of from 1-3 gr. (0.065-0.2 gm.), 
in pills made with kaolin or soft paraffin, and these should be 
taken after meals in large drafts of water. As potassium 
permanganate is a highly irritating salt, and, moreover, as it is 
at once decomposed in the stomach into the black oxid of 
manganese, the latter preparation (Mangani Dioxidum Prae- 
cipitatum, U. S. P.), which is free from irritant properties, may 
be substituted with advantage. Its dose is from 2-5 gr. (0.1- 
0.3 gm.). 

APIOL. 

Apiol is an oleoresin obtained from Apium Petroselinum, or 
garden parsley. It is a greenish oily liquid from which a crys- 
talline stearoptene is obtained, known as white apiol. The dose 
of apiol is from 5-10 min. (0.3-0.6 c.c), in capsules. When 
given for a few days before the expected period it is a fairly 
reliable emmenagogue. It was formerly recommended as a 
substitute for quinin in malaria, but it proved to be useless. 



SENECIO— ACID l\V OXALICUM. 249 

SENECIO. 

(Ragwort; Life Root.) 

Senecio is the entire plant of Senecio aureus, a perennial 
herb growing in the northern and western parts of the United 
States. In the form of a fluid extract or tincture it has been 
highly recommended as a corrective of functional amenorrhea 
and dysmenorrhea. Murrell compares its action to that of 
potassium permanganate. The dose of the fluid extract is 
from J-i fl. dr. (2.0-4.0 c.c.i; of the tincture, 1-2 fl. dr. (4.0- 
8.0 c.c). 

CANTHARIS, U. S. P. 

(Cantharides.) 

The stimulant influence of cantharides on the uterus is 
probably the indirect effect of its irritant action on the 
urinary passages. Small doses of the tincture — 1-3 min. (0.06- 
0.2 c.c.) — are generally prescribed in combination with other 
members of the same class, as in the well-known emmenagogue 
mixture of Dewees, which Wood regards as the most effective 
combination ever made in atonic amenorrhea. The formula of 
Dewees' mixture is as follows : 

R Tincturce ferri chloridi, fjiij (11.0 c.c); 

Tincturze cantharidis, f^ss (2.0 c.c.) ; 

Tincturae aloes, f|ss~(i5.o c.c.) ; 

Tincturae guaiaci ammoniatae, ^E^ ss (45 -° c - c -) '■> 

Syrupi, q. s. ad f^vj (180.0 c.c). — M. 

Sig. A tablespoonful three times a day. 

ACIDUM OXALICUM. 

I Oxalic Acid; H 2 C 2 4 - H 2 0.) 

Oxalic acid occurs as transparent, prismatic crystals of a 
very acid taste. It is readily soluble in water and in alcohol. 

Physiologic Action and Therapeutics. — Oxalic acid 
is a powerful uterine stimulant, in full doses quite capable of 
exciting labor pains and of expelling the product of concep- 
tion. As Poulet first demonstrated, it is an efficient emmen- 
agogue if given in doses of -J— J- gr. (0.016-0.02 gm.), thrice 
daily. Larger doses should not be given. Talley has reported 
a case of acute poisoning in an anemic girl from the admin- 
istration of three doses of J gr. (0.03 gm.) each, at intervals of 
four hours. On account of its irritant properties it should be 
taken well diluted, after meals. 

Oxalic acid is an active germicide, and its saturated solution 
has been highly recommended by Kelly and others as a dis- 
infectant for the hands. 



250 EMMENAGOGUES. 

Toxicology. — The poisonous properties of oxalic acid do 
not depend solely upon its corrosive action, for the neutral 
oxalates may also cause death by paralyzing the central ner- 
vous system. The resemblance of the drug to Epsom salts has 
led to many fatal mistakes. When swallowed in a concen- 
trated form it causes the usual symptoms of an irritant poison ; 
when taken in dilute form it is absorbed and induces muscu- 
lar weakness, cyanosis, coma, and collapse. The chemical 
antidote is chalk or lime, which acts by forming an insoluble 
and inert calcium oxalate. The salts of potassium and sodium 
cannot be used as antidotes since they form soluble and poison- 
ous oxalates. 

MYRRHA, U. S. P. 

(Myrrh.) 

Myrrh is a gum-resin obtained from Commiphora Myrrha, a 
small tree growing in eastern Africa and Arabia. It appears in 
the form of brownish-red irregular-shaped tears, having an 
agreeable aromatic odor and a bitter acrid taste. 

Preparations. Dose. 

Tinctura Myrrhae, U. S. P 10-30 min. (0.6-2.0 c.c). 

Tinctura Aloes et Myrrhse, U. S. P. (10 per 

cent, of each) \-2 fl. dr. (2.0-8.0 c.c). 

Mistura Ferri Composita, U. S. P. (Griffith's 

mixture; ferrous sulphate, 6; myrrh, 18; 

sugar, 18; potassium carbonate, 8; spirit of 

lavender, 60; rose-water, to make 1000) . . 1-4 fl. dr. (4.0-15.0 c.c). 
Pilulse Aloes et Myrrhae, U. S. P. (aloes, 2 gr.— 

0.13 gm. ; myrrh, I gr. — 0.06 gm.) .... I -4 pills. 
Pilulae Rhei Compositae, U. S. P. (aloes, \\ 

gr. — 0.1 gm.; rhubarb, 2 gr. — 1.3 gm.; 

myrrh, I gr. — 0.06 gm.) 1-5 pills. 

Therapeutics. — Myrrh is used as an emmenagogue and 
as a stimulant to mucous membranes. When employed-as an 
emmenagogue, it is usually associated with iron or aloes. The 
tincture, diluted with water, or with a weak solution of borax 
or potassium chlorate has been extensively employed as a 
local application in ptyalism, ulcerative stomatitis, and spongy 
gums. 

B Potassii chloratis, gr. xl. (2.6 gm.) ; 

Tinctura? myrrhae, f^* ss (45 -° cx -) I 

Tincturae benzoinae comp., f^vj (24.0 c.c.) ; 

Liquoris antiseptici, q. s. ad f§iv ( 1 15.0 c.c). — M. 

Sig. Teaspoonful in a wineglassful of water as a mouth- wash every two hours. 

Myrrh was also used at one time as a stimulant expectorant in 
chronic bronchitis, but it has been replaced by more efficient 
remedies. 



HEDE OMA—SABINA. 2 5 I 

HEDEOMA, U. S. P. 

(Pennyroyal.) 

Pennyroyal is the leaves and tops of Hedeoma pulegioides, an 
annual herb indigenous to North America. It contains a vola- 
tile oil, a bitter principle, and tannin. 

Preparations. Dose. 

Oleum Hedeomse, U. S. P 3~io min. (0.2-0.6 c.c). 

Infusum Hedeomce 1-2 fl. oz. (30.0-60.0 c.c). 

Therapeutics. — Pennyroyal, in the form of a hot infusion, 
has a popular reputation as an emmenagogue which is not 
altogether unmerited. It is especially employed in acute 
suppression brought on by exposure. 

TANACETUM. 

(Tansy.) 

Tansy is the leaves and tops oiTanacetum vulgare, a peren- 
nial herb growing wild in Europe and Asia, and naturalized in 
North America. Its active principle is a volatile oil. 

Preparation. Dose. 

Oleum Tanaceti' 1-3 min. (0.06-0.2 c.c.). 

Physiologic Action and Therapeutics. — Tansy has 
long been used as a domestic remedy in amenorrhea, the 
herb itself being generally employed in doses of from J— 1 
dr. (2.0-4.0 gm.), in decoction. The oil has also been taken 
frequently in order to produce abortion, many times with ill 
success, but with grave or even fatal results to the mother. 
Large doses of the oil cause severe abdominal pain, vomiting, 
epileptiform convulsions, coma, and collapse. Tansy was for- 
merly employed as an anthelmintic, but this use of the drug 
is now obsolete. 

SABINA, U. S. P. 

(Savine.) 

Savine is the tops of Juniperus Sabina, an evergreen shrub 
growing in northern Europe, Asia, and America. Its active 
constituent is a volatile oil. 

Preparations. Dose. 

Oleum Sabinae, U. S. P 3-6 min. (c.2-0.4 c.c). 

Fluidextractum Sabinse, U. S. P 5-15 min. (0.3-1.0 c.c). 



252 OXYTOCICS, OR ECBOLICS. 

Physiologic Action and Therapeutics. — The action 
of oil of savine resembles that of oil of juniper, but it is more 
irritant. Large doses cause abdominal pain, vomiting, purg- 
ing, anuria, unconsciousness, and collapse. In pregnant women 
the intoxication generally culminates in abortion. Owing to the 
fact that expulsion of the fetus does not occur until the irrita- 
tion of the intestinal canal and kidneys is sufficiently violent to 
endanger life, many cases of fatal poisoning have resulted from 
the use of the drug as an abortifacient. Oil of savine has long 
borne a reputation in amenorrhea and in certain forms of Men- 
orrhagia, but at the present time it is rarely prescribed. 

RUTA. 

(Rue.) 

Rue is the leaves of Ruta graveolens, a perennial plant 
indigenous to Southern Europe, and cultivated in this country. 
It contains a volatile oil. Its action is similar to that of savine. 
The dose of the oil is from 3-6 min. (0.2-0.4 c - c -)- 

PULSATILLA. 

Pulsatilla (see p. 65) has been recommended in sudden sup- 
pression of menstruation induced by chill, but its use as an 
emmenagogue is superfluous. 



OXYTOCICS, OR ECBOLICS. 

Oxytocics are drugs that tend to accelerate parturition by 
increasing the expulsive force of the uterus. It is conceivable 
that they may act directly by stimulating the unstriped muscle 
of the uterus, or indirectly by influencing a center for uterine 
contraction supposed to exist in the lumbar spinal cord. The 
chief oxytocics are : 



Ergot. 


Hydrastis. 


Quinin. 


Cotton-root bark. 




Corn smut. 



Indications. — Oxytocics may be employed during labor to 
hasten the expulsion of the fetus ; at the close of labor, to 
prevent or to check postpartum hemorrhage ; and in the 
puerperium to overcome certain forms of subinvolution. 

ERGOTA, U. S. P. 

(Ergot; Ergot of Rye ; Secale Cornutum.) . 

Ergot is the sclerotium of a parasitic fungus, Claviceps pur- 
purea, which replaces the grain of common rye, Secale cereale* 



ERG OTA 253 

The sclerotium represents a stage in the life-history of the 
fungus which is intermediate between that of the mycelium or 
spawn, and that of the spore-bearing thallus. Ergot is obtained 
principally from Russia, Germany, and Spain. The official 
preparation is horn shaped, about an inch (2 or 3 cm.) long, 
and -§- inch (3 mm.) thick ; externally it is purplish black, and 
internally, whitish with pinkish striae. It has a peculiar heavy 
odor and an oily, disagreeable taste. The chemistry of ergot 
has not been definitely determined. Kobert separated in an 
impure state three bodies — ergotinic acid, cornutin> and sphace- 
linic acid — and subsequently Jacobj demonstrated that the ac- 
tivities of sphacelinic acid depended upon an unstable resinous 
body, sphacelotoxin. None of these constituents, however, rep- 
resents completely the activities of the crude drug. Ergotinic 
acid is a sapotoxin. Taken by the mouth, it causes gastro- 
intestinal irritation, but nothing more, as it is not absorbed. 
Injected intravenously, it induces paralysis of the central ner- 
vous system. Cornutin is an alkaloid. It first stimulates and 
then depresses the central nervous system, particularly the 
medulla. Lethal doses cause restlessness, salivation, vomiting, 
purging, clonic convulsions, and, finally, death from asphyxia. 
Sphacelotoxin is the most important constituent of ergot. It 
has a fourfold action : it produces severe irritation of the ali- 
mentary canal ; it causes constriction of the arterioles, extreme 
enough in some animals to induce gangrene of certain periph- 
eral parts ; it excites contractions in the uterus, which, if gravid, 
may result in abortion, and, in very large doses, it depresses 
the central nervous system. 

Preparations. Dose. 

Vinum Ergotse, U. S. P 1-4 fl. dr. (4.0-15.0 c.c). 

Fluidextractum Ergotse, U. S. P \- 1 fl. dr (2.0-4.0 c.c). 

Extractum Ergotae, U. S. P 5—15 gr. (0.3-1.0 gm.). 

Ergotin (Bonjean's Ergotin : a purified hydro- 
alcoholic extract of ergot) 3-logr. (0.2-0.65 gm.). 

Physiologic Action. — Circulatory Action. — The sub- 
cutaneous injection of ergot in moderate doses is followed 
by constriction of the arterioles, with an increase in the 
arterial pressure, which is due to the stimulant effect of the 
drug on the vasomotor center, and probably, also, to its 
direct action on the muscular coats of the vessels. When 
the injection is made intravenously the blood-pressure is 
first lowered and then raised, the primary fall, according to 
Wood, being due to temporary depression of the heart from 
direct contact with the drug. After toxic doses there may 
be a marked and continuous fall in the blood-pressure from 
depression of both the vasomotor center and the heart. The 



254 OXYTOCICS, OR ECBOLICS. 

rise of blood-pressure is often accompanied by slowing of the 
heart, which seems to be due to stimulation of the inhibitory 
center in the medulla. The gangrene observed in chronic 
poisoning is the result of prolonged constriction of the arterioles 
and the consequent formation of hyaline thrombi. Among 
the lower animals the gangrenous effect of ergot is readily 
produced in fowls and pigs, but not in cats, dogs, or rabbits. 

Nervous System. — Ordinary doses of ergot, if not long con- 
tinued, have no appreciable influence on the nervous system. 
In one form of chronic poisoning, however, nervous phenomena 
are pronounced. These include paresthesia, anesthesia, con- 
vulsions, tonic contractions of the limbs, ataxia, mental dulness, 
and dementia. Grigorjeff has found postmortem in animals 
slowly poisoned with ergot degenerative changes in the 
central nervous system, especially in the posterior columns of 
the spinal cord. 

Alimentary Canal. — Ergot increases the peristaltic move- 
ments of both the stomach and intestine, probably through its 
direct action on their muscular coats. Even in therapeutic 
doses it may excite nausea and vomiting. 

Uterus. — In the parturient woman small doses of ergot 
induce uterine contractions which often closely resemble the 
rhythmic contractions observed in normal labor. After full 
doses, however, the contractions usually become very power- 
ful, and uninterrupted or tetanic. The preparations of the 
drug on the market vary so much in activity that it is quite 
difficult to predict the effect of an average dose in a given case. 
The influence of ergot on the gravid but non-parturient uterus 
is less marked, but there is ample evidence to show that in 
animals it is capable of originating expulsive movements that 
culminate in abortion. It is not definitely known whether the 
ecbolic action of ergot is due to direct stimulation of the 
unstriped muscle of the uterus itself, or to an influence exerted 
on the uterine center in the spinal cord. It is probably in 
part, at least, of peripheral origin. 

Muscles. — On the voluntary muscle ergot has no effect, but 
it seems to have a stimulant influence on the involuntary 
muscle throughout the body. 

Toxicology. — In acute ergot poisoning the symptoms most 
commonly observed are nausea, vomiting, intense thirst, cold- 
ness of the surface, headache, stupor, and generalized purpura, 
The pulse may be unduly slow, or, after very large doses, 
rapid and feeble. 

Chroiiic ergot poisoyiing has not been uncommon. In nearly 
every instance it has resulted from eating bread made of 



ERGOTA. 255 

ergotized grain. It assumes two forms : Spasmodic ergotism 
and gangrenous ergotism. The first is characterized by ma- 
laise, inordinate craving for food, vomiting, diarrhea, headache, 
disordered vision, tinnitus aurium, formication, numbness of 
the extremities, ataxia, convulsive seizures, painful contractions 
of the muscles, and mental hebetude, followed by delirium or 
acute dementia. 

Gangrenous ergotism is characterized by exhaustion, cold- 
ness of the surface, cyanosis, aching of the limbs, and the 
development of gangrenous areas in various parts of the body, 
especially in the fingers and toes. Cataract has also been fre- 
quently observed. 

Therapeutics. — Ergot may be used during parturition, 
cautiously and in small doses, to hasten the expulsion of the 
fetus, when the cause of the delay is simply uterine inertia, and 
not mechanical obstruction, but it is very rarely necessary. 
Its use in full doses, especially when dystocia is the result of 
contracted pelvis, rigid os uteri, displacement of the uterus, 
abnormal presentation, or other physical abnormity, may 
prove disastrous by exciting tetanic contraction and conse- 
quent asphyxia of the child or even rupture of the uterus. 
At the close of labor, after the head is born, ergot is very 
useful in preventing postpartum hemorrhage. It may be used 
also after the removal from the uterus of any abnormal con- 
tents — retained placenta, clots, etc. — to control hemorrhage 
that has already occurred. It is a useful adjuvant in the 
treatment of certain cases of subinvolution of the uterus , but the 
possibility of its affecting the child through the mother's milk 
must be borne in mind. The treatment of 'uterine fibroids with 
repeated injections of ergot, as recommended by Hildebrandt 
in 1872, has met with a very limited success. By contracting 
the blood-vessels of the uterus, however, the drug may tempo- 
rarily control hemorrhage, and in rare instances check the 
growth of the tumor, or even bring about its involution. The 
treatment is adapted only to small intramural fibroids that are 
soft and vascular. 

While the efficacy of ergot in certain forms of metrorrhagia 
has been conclusively proved, there is no satisfactory evidence 
that the drug is of value in other forms of hemorrhage, such 
as hemoptysis, hematuria, or hematemesis. On the contrary, 
our knowledge of its physiologic action indicates that it may 
be productive of harm. Granting that ergot can lessen the 
caliber of eroded, degenerated, or seriously wounded vessels, 
there is no reason for supposing that its influence is restricted 
to the vessels concerned in the bleeding, and if such is not the 



256 OXYTOCICS, OR ECBOIICS. 

case, the universal constriction of the arterioles induced by 
the drug, and the consequent rise in the general blood press- 
ure must favor the escape of blood from the injured vessels 
and militate against the formation of an occluding thrombus. 
Ergot has been used with some success in diabetes i?tsipidus 
(Da Costa, Ringer), in colliquative sweats (Wood), and in head- 
aches of a migraine type (Thomson). It has also been recom- 
mended in a variety of other affections, such as diabetes melli- 
tus, acute meningitis, myelitis, splenic enlargements, acute 
dysentery, and hyperemic skin diseases, but it has not borne 
the test of experience. 

Administration. — The preparations of ergot on the market 
are exceedingly variable in strength ; some are absolutely 
inert. The best preparation for internal use is a good fluid 
extract. It is less liable to excite nausea when taken after 
meals. In urgent cases the drug should be given hypoder- 
mically, notwithstanding its tendency to produce local inflam- 
mation. The injections should not be made directly beneath 
the skin, but deeply into a muscle. An aqueous solution of 
the extract, freshly prepared and filtered, may be employed. 
Bonjean's ergotin is unreliable. 

OTHER OXYTOCICS- 

Quinin (see p. 416). — This drug has some power of in- 
creasing the rapidity and energy of the uterine contractions 
when they have once begun ; its action, however, is inconstant. 
The contractions are much less prolonged than those excited 
by ergot, and are probably due to an influence exerted directly 
on the uterine muscle. As the drug does not seem capable 
of originating labor-pains, it cannot be considered an active 
ecbolic, and the cases of abortion that have been reported as 
following its administration have no doubt been due either to an 
idiosyncrasy or to the original disease for which the quinin was 
prescribed. According to some obstetricians, its use during 
labor distinctly increases the tendency to postpartum hemor- 
rhage. 

Hydrastis (see p. 379).— Both the natural alkaloid of this 
drug, hydrastin, and its artificial derivative, hydrastinin, are of 
considerable value in controlling hemorrhage from the uterus. 
It is definitely known that both drugs induce constriction of 
the peripheral vessels, but whether their efficacy in metrorrhagia 
is due, in part, to their power of exciting contraction of the 
uterine muscle is a moot question. Many writers, how- 
ever, maintain that these alkaloids have pronounced ecbolic 



DIAPHORETICS, OR SUDORIFICS. 2$? 

properties, and are capable, in sufficient dose, of producing 
abortion. 

As a uterine hemostatic hydrastinin is preferable to hydras- 
tin. It is particularly efficacious in simple menorrhagia of 
young girls and in metrorrhagia following abortion or resulting 
from disease of the adnexa. Hemorrhages resulting from the 
presence of cancer or fibroids are not much affected by the 
drug. The dose of the official hydrastinin hydrochlorid is 
from \- 1 gr. (0.016-0.065 gm.). When a prompt effect is re- 
quired, it should be given hypodermically in the form of a 10 
per cent, aqueous solution. , 

Cotton-root Bark. — This drug {Gossypii Cortex, U. S. P.) 
is said to have been much valued among the slaves of the 
South as an abortifacient. Some obstetricians have claimed 
for it an action resembling that of ergot. The dose of the 
fluid extract as an ecbolic is from J-2 fl. dr. (2.0-8.0 c.c). 

Com Smut. — This drug {Ustilago Maydis) is a fungus 
growing on the stems and tassels of Zea Mays, or Indian corn. 
According to some obstetricians, the fluid extract, in doses of 
from J-i fl. dr. (2.0-4.0 c.c), induces in the parturient uterus 
vigorous but intermittent contractions, and is, therefore, a 
useful stimulant when the labor pains are feeble from ex- 
haustion. 



DIAPHORETICS, OR SUDORIFICS. 

Diaphoretics are agents that promote the secretion of 
sweat. They may act by stimulating the terminations of the 
secretory nerves, by stimulating the cells in the central nervous 
system (sweat centers) from which those nerves arise, by dilat- 
ing the blood-vessels of the skin, or, reflexly, by irritating per- 
ipheral sensory nerves. The activity of the sweat glands may 
also be increased by external heat, muscular exercise, dyspnea, 
strong emotion, and nausea. 

Although dilatation of the cutaneous vessels promotes per- 
spiration when other conditions are not unfavorable, the 
mechanism of sweat secretion is in large measure independent 
of the blood-flow. Thus, in fever the flushed skin may be 
unnaturally dry, while in collapse, with pallid skin, there may 
be free perspiration. External heat may act partly by inducing 
hyperemia of the skin, but that it acts chiefly by stimulating 
the sweat-fibers reflexly through the cutaneous sensory nerves 
appears evident from the fact that exposure of a part to a high 
17 



258 DIAPHORETICS, OR SUDORIFICS. 

temperature does not cause sweating if all the nerves leading 
to the part be severed. Muscular exercise probably acts by 
increasing the flow of blood to the glands and by stimulating 
the peripheral nerves and nerve-centers. Dyspnea acts by 
increasing the proportion of venous blood, the latter being a 
powerful stimulant of the sweat-centers. Strong emotions 
affect secretion probably also by action on the nerve-centers. 
The sweating that attends nausea is, no doubt, induced reflexly 
by stimulation of the sweat-centers through the sensory nerves 
of the stomach. Among drugs, pilocarpin owes its diaphoretic 
effect to stimulation of the nerve-endings in the gland-cells, 
while alcohol and opium favor sweating, probably by dilating 
the skin vessels. The drugs most commonly employed as 
diaphoretics are : 

Pilocarpus (pilocarpin). Spirit of nitrous ether. 

Opium. Ammonium acetate. 

Ipecacuanha. Warburg's tincture. 

Indications. — Diaphoretics are given : (1) To promote the 
absorption of dropsical fluid ; (2) to rid the system of peccant 
matters ; and (3) to arrest the development of local conges- 
tions or inflammations that have resulted from exposure to 
cold. 

■ PILOCARPUS, U. S. P. 

( Jaborandi. ) 

According to the Pharmacopeia pilocarpus is the leaflets of 
Pilocarpus microphyllus and of Pilocarpus Jaborandi, shrubs 
growing in South America. It contains three alkaloids — pilo- 
carpin, pilocarpidin, and isopilocarpin — which produce similar 
effects, but pilocarpin is the most active, and is present in 
larger quantity (J-J per cent.) than the others. Jowett, in a 
recent investigation, was unable to find in the leaves at present 
obtainable any trace of an alkaloid answering to the descrip- 
tion of jaborin, discovered by Harnack and Meyer, and which 
is said to resemble atropin in its action. 

Pilocarpin yields soluble crystalline salts, of which the ni- 
trate (Pilocarpine Nitras, U. S. P.) and the hydrochlorid (Pilo- 
carpine Hydrochloridum, U. S. P.) are most commonly em- 
ployed. The dose of either of these salts is from -^-\ gr. 
(0.005-0.03 gm.). 

Preparation. Dose. 

Fluidextractum Pilocarpi, U. S. P 20-60 min. (1.2-4.0 c.c). 



PILOCARPUS. 259 

Physiologic Action. — Secretion. — The dominant action 
of pilocarpin is on the secretory glands of the body. Under 
its influence the sweat and saliva are enormously increased. 
It increases also, but to a less extent, the lacrimal, nasal, bron- 
chial, gastric, and intestinal secretions. Milk, bile, and urine 
are not materially increased. As its effect on secretion is com- 
pletely suspended by atropin, it would seem to be due to 
stimulation of the peripheral fibers of the nerves supplying the 
glands. 

Circulatory System. — The action of pilocarpin on the circu- 
lation has not been definitely determined. In certain animals, 
like the frog, cat, and rabbit, it appears first to stimulate and 
then to depress the peripheral fibers of the vagus, in conse- 
quence of which the pulse is primarily slowed and then quick- 
ened. After large doses the pulse again becomes slow, and 
the blood pressure falls considerably below normal, owing to 
weakness of the heart and vasomotor center. In man the cir- 
culation appears to be affected in a somewhat different manner ; 
the pulse-rate is usually increased, the peripheral vessels are 
dilated, and the blood pressure is lowered. Not infrequently, 
however, there is a distinct rise in the arterial pressure, especi- 
ally at first. Although the evidence, derived from experimental 
sources, is in some respects contradictory, clinical experience 
is in accord with the view that pilocarpin, at least in full doses, 
is a circulatory depressant. 

Nervous System. — In therapeutic doses pilocarpin has no 
action on the central nervous system. In certain animals 
toxic doses induce convulsions which are probably of spinal 
origin. 

Respiration. — Small doses are without effect; toxic doses 
depress the respiratory center. In the presence of a weakened 
circulation the drug tends to induce pulmonary edema. 

Muscles. — Pilocarpin excites contractions in the unstriped 
muscle of the iris, stomach, intestines, bladder, uterus, and 
spleen, probably by stimulating the terminations of the nerve- 
fibers supplying the muscle. 

Alimentary Canal. — Nausea and vomiting are sometimes 
induced by jaborandi or pilocarpin, especially when the drug 
is given by the mouth. This effect is probably caused by its 
irritant action on the peripheral nerves of the stomach. It 
also increases both gastric and intestinal peristalsis. 

Eye. — Pilocarpin, especially when applied locally, contracts 
the pupil by stimulating the terminal filaments of the oculo- 
motor nerve. It also decreases the intra-ocular tension. 



260 DIAPHORETICS, OR SUDORIFICS. 

Blood. — It has been shown that pilocarpin, probably from 
some influence exerted on the spleen and lymphatic glands, 
increases the lymphocytes of the blood. 

Temperature. — Coincident with the profuse diaphoresis 
which the drug excites, and probably dependent upon it, there 
is a well-marked fall in the body-temperature. 

Toxicology. — The chief phenomena of pilocarpin poison- 
ing are salivation, profuse sweating, nausea and vomiting, 
serous purging, contraction of the pupils, muscular tremors, 
and collapse. Atropin is an effective physiologic antidote. 

Idiosyncrasy and Untoward Effects. — The action of 
pilocarpin in man is by no means constant. Occasionally even 
small doses are followed by severe cardiac depression or pul- 
monary edema. Swelling of the salivary glands, profuse sali- 
vation, and strangury have also been observed after its adminis- 
tration. On the other hand, there may be a peculiar insus- 
ceptibility to its action, as in a case reported by Hare, in which 
a woman of thirty years received f gr. (0.05 gm.) of pilocarpin 
hydrochlorid hypodermically in half an hour without any 
effect. According to Ringer, children are far less susceptible 
than adults. 

Therapeutics. — Pilocarpin in doses of from ^ ^ 2 gr. 
(0.004-0.005 gm.) is very useful in promoting moderate dia- 
phoresis in acute and chronic parenchymatous nephritis. It 
tends to avert uremia by relieving the congestion of the kidneys 
and by ridding the blood of poisonous matters. Its action 
should be supplemented by external heat, and any depression 
or faintness should be combated with strychnin or ammonia. 
The remedy may be repeated every other day or even every 
day. Samuel West believes that there is no more useful drug 
in chronic interstitial nephritis than pilocarpin in small doses 
by the mouth. He finds that headache, irritability, digestive 
disturbances, and dry skin often yield rapidly to a dose or two. 
In acute uremia larger doses, \-\ gr. (0.01-0.02 gm.) may be 
employed in conjunction with hot-air or vapor baths. In 
puerperal eclampsia the drug is very often badly borne. In 
general dropsy, especially that due to Bright's disease, pilo- 
carpin is a valuable aid to absorption. In local effusions, how- 
ever, such as occur in the pleura and pericardium, it is rarely 
effective. It is sometimes employed for its diaphoretic effect 
in muscular rheumatism^ acute coryza, and acute sthenic affec- 
tions. 

Daily injections of pilocarpin (l gr. — 0.0 1 gm.), as first em- 
ployed by Politzer in 1880, have given gratifying results in 



OTHER DIAPHORETICS. 26 1 

some forms of acute and subacute labyrinthine disease, charac- 
terized by deafness, tinnitus aurium, and vertigo. 

The action of pilocarpin on the eye is much like that of 
eserin, but it is decidedly less powerful. It has been used to 
lessen intra-ocular tension in glaucoma, but eserin is more reli- 
able. When, however, a gentle but persistent stimulant effect on 
the ciliary muscle is desirable, as in cases of accommodative asthe- 
nopia, pilocarpin will be found very serviceable. As an adju- 
vant to mixed treatment daily injections of pilocarpin have 
sometimes proved efficacious in intractable cases of syphilitic 
keratitis. There is sufficient evidence to prove that the internal 
administration of pilocarpin promotes the growth of hair, and 
at the same time renders it darker and coarser. Favorable 
results from the hypodermic use of the drug in extensive alo- 
pecia and alopecia areata have been reported by Simon, Pick, 
Morris, Pringle, and others, but the practice of applying the 
remedy in the form of lotions to the scalp in premature bald- 
ness is of doubtful utility. 

Contraindications. — The existence of grave cardiac or 
pulmonary lesions prohibits its use. Caution should be exer- 
cised in giving pilocarpin to women advanced in pregnancy, 
as the drug possesses some power as an abortifacient. 

Administration. — On account of the uncertain alkaloidal 
strength of the fluid extract and its greater tendency to cause 
vomiting, one of the salts of pilocarpin is usually preferable. 
The latter may be given by the mouth, but when a prompt 
effect is desired, it should be given hypodermically. Its dia- 
phoretic action is greatly facilitated by the application of heat 
to the patient. Circulatory failure should be combated with 
ammonia, strychnin, or alcohol, and pulmonary edema with 
hypodermic injections of atropin. According to Tyson, a 
freshly prepared infusion may be injected into the rectum with 
prompt results. Four ounces (120.0 c.c.) of hot water should 
be poured on a dram (4.0 gm.) of jaborandi leaves, and, when 
sufficiently cool, strained and injected. 

OTHER DIAPHORETICS. 

Opium (see p. 91). — As a diaphoretic, opium is usually 
employed in the form of Dover's powder, or powder of ipecac 
and opium. This preparation, in doses of from 5-10 gr. (0.3- 
0.6 gm.), produces a mild sudorific effect, and is useful in 
breaking up acute catarrhal conditions of the respiratoy organs 
and in relieving so-called muscular rheumatism. It should be 



re: A.vr;j:-yr:\T.\\\ 

borne in mind that large doses not infrequently cause nausea 

:er. :he <:o:: 

Spirit of Nitrous Ether >- e ::;'.— - . 

S Iritus : bei is N U S P.) is an alcoholic solu- 

tion of ethyl nitrite, yielding, when freshly preparec > than 

n times its c .me of nitrogen dioxid, the equivalent 

of about 4 per cent, of pure ethyl nit: 
inflammable liquid, having a pale yellowish or gre< 
tint, a pleasant ethereal odor, and a sharp, burning taste. On 
exposure to light and air it rapic urates. The dos. 

an adult is from |~2 fl. dr. (:.ChS.o ex.) ; for a child, 10-30 
min. (0.6- _ D c c 

In medicinal doses nitrous ether, acts as a mild diaphoie 
diuretic, and antispasmodic When the patient is kept well 
cover; e. //':. r ::> e.eiee i:vi>: . 

pronounced than its diuretic effect, and the reverse is 
when the patient is lightly covered Toxic doses produce 

:ptoms resembling poisoning by amyl nitrite and o 
nitrites. Sweet spirit of niter is a useful remedy in the fnild 
febrile affections of children ; it is best given in small doses, 
well diluted with hot water, at frequent in: s A s a dti 
: s efficacious in relieving oliguria due to fever or acute cott- 
f:-sr:\- . . -' ;';.'• ":.:".v:/ 

Incompatibles. — Iodids, ferric sulphate, mucilage of aca 
tannic acid, tincture of guaiacum, and antipyrin. acetan 

Ammonium Acetate. — 7e.i< ;^:r.;::-::-.; - . ie. 

the form of its official solution, the spirit of minder 

:s U 5 ng as the patient 

warm or cool it acts as a feeble diaphoretic or diuretic 
often used in febrile diseases as a vehicle it of nitrous 

ether or aconite Its dose is from 1-4 e- 15 c 

Warburg's Tincture see ;e _ee\ — 77.5 \w 

doses of 7 - Q ex is capable of inducing cori 

- sating. To be effect I should en undilu. 

drinks should be withheld. It has been highly commended in 
:he • .e. './..: \; ;.ve ./" ->:.:.'.: r.:.' v: :\ 



■^ ■ 



ANTIHYDROTICS. 

Antihydrotics are agents thai check 
Theoretical! nay ad by lessen the 

..it-centers ; by depressing the terminal ibers the sea 



AX Til I YDR O TICS. 26 3 

nerves, or, possibly, the secretory gland-cells themselves ; or 
by stimulating the respiratory center. Brunton has called 
attention to the close relation existing between respiratory 
depression and the occurrence of colliquative sweats. He 
states that when the respiratory center is exhausted from any 
cause it responds less readily than the sweat-centers to the 
stimulating influence oi venous blood, in consequence of which 
profuse sweating results. This teaching accords with the well- 
known fact that respiratory stimulants are frequently efficacious 
in controlling the night-sweats o( phthisis. The most import- 
ant antihydrotics are : 

pin. ^aricin. 

Sulphuric acid. Picrotoxin. 

Camphoric acid. Tellurium compounds. 

Thallium acetate. 

Gallic acid, ergot, and zinc oxid have also been employed, 
but they are of little value. In addition to the internal reme- 
dies, certain external applications are useful in controlling 
excessive perspiration ; thus, sponging the surface with vinegar 
and water or a hydro-alcoholic solution of tannic acid or alnm 
sometimes affords relief. A weak solution of formalin, as 
recommended by Hirschfeld, is a powerful antihydrotic, but 
its irritant effects on the eyes and respiratory tract forbid its 
use when the sweating is general. Recently, Strasburger has 
substituted for the formalin solution a dusting-powder of ta?ino- 
form, a condensation product of tannin and formaldehyd. 
The application, at bedtime, of a powder composed of 1 part 
of tannoform to 2 parts of talcum, is said to render excellent 
service in preventing the night-sweats of phthi 

In local hyperidrosis internal remedies are rarely of benefit ; 
the best results are obtained from external applications, the 
most effective being dusting-powders containing tannoform, 
salicylic acid, or boric acid, or a pigment of formalin and alco- 
hol. 

Atropin (see p. 75). — This is the most powerful of the anti- 
hydrotics. It checks the secretion of the sweat-glands by 
paralyzing the terminations of the secretory nerves. In doses 
of from yJt - ttht g r - f 0.0003 2-0.00064 gm.) at bedtime it often 
effectually controls the exhausting night- sweats of phthisis ; 
unfortunately, however, its repeated use is frequently attended 
by untoward symptoms, such as dryness of the throat, thirst, 
and dimness of vision. The tincture of belladonna is some- 
times employed as a lotion in local hyperidrosis occurring about 
the hands and feet. 



264 ANTIHYDR O TICS. 

Sulphuric Acid (see p. 448). — Aromatic sulphuric acid has 
been used longer and perhaps more extensively than any of 
the other antihydrotics. Its power, however, compared with 
that of drugs more recently introduced, is very feeble. It 
should be given in doses of from 5-10 min. (0.3-0.6 c.c.) 
largely diluted with cool water. 

ACIDUM CAMPHORICUM, U. S. P. 

(Camphoric Acid; C 8 H u (COOH) 2 .) 

Camphoric acid is a crystalline powder made by oxidizing 
camphor with nitric acid. It is odorless, of a slightly acid 
taste, soluble in 160 parts of cold water, and readily soluble 
in alcohol and ether. The dose is from 20-30 gr. (1.3-2.0 
gm.). On account of its sparing solubility in water it is best 
prescribed in powders, in capsules, or in an elixir. 

Therapeutics. — Camphoric acid is an antiseptic and anti- 
hydrotic. As an antiseptic it has been used both internally 
and externally, but in this respect it is inferior to many other 
drugs in common use. It is of much greater service in 
checking excessive perspiration, but the manner of its action is 
unknown. As it is rapidly eliminated in the urine it is best 
given about two hours before the time at which the sweating 
is likely to occur. Its drawback is its tendency to cause 
nausea and vomiting. 

AGARICIN. 

Agaricin is a crystalline body obtained from Polyporus 
officinalis, a fungus growing on the larch tree. The fungus 
itself (white agaric or purging agaric), although an active 
irritant, was recommended for excessive sweating by de Haen 
as early as 1768. Agaricin is an impure form of agaric or 
agaricic acid, which appears as a white, lustrous powder, odor- 
less, almost tasteless, and slightly soluble in water and alcohol. 
The dose of agaricin is from \- 1 gr. (0.016-0.065 gm.), and of 
agaric acid, -J-— i gr. (0.01-0.03 gm.). The latter is the less 
irritating and more reliable preparation. 

Physiologic Action and Therapeutics. — When admin- 
istered by the mouth in large doses agaricin acts as an irritant 
and induces severe vomiting and purging. According to Hof- 
meister, when it is administered to animals subcutaneously or 
intravenously in sufficient dose it first stimulates and then 
depresses the centers of the medulla oblongata, death ulti- 
mately resulting through cardiac or respiratory paralysis. 
The drug is chiefly interesting to the therapeutist on account 



PICROTOXINUM— TELLURIUM. 265 

of its effect on the perspiration. Like atropin, it arrests the 
secretion of sweat probably by paralyzing the nerve-endings 
in the sudoriferous glands. Unlike atropin, however, it has 
no influence on the salivary or lacrimal secretions. 

Agaric acid is preferable to agaricin, being less liable to 
cause nausea. As it is absorbed slowly it should be given 
several hours before the time of the expected sweating. It 
may be prescribed in the form of a pill or powder. 

PICROTOXINUM. 

(Picrotoxin.) 

Picrotoxin is a neutral principle obtained from fish berries — 
Anamirta cocculns and Anamirta paniculata, growing in India 
and the Malayan Islands. It is a colorless, shiny, crystalline 
powder, odorless, and of an intensely bitter taste. It is soluble 
in alcohol and in acidulous or alkaline solutions, but only 
sparingly so in water. The dose is from -g ^ ■ £ gr. (0.0008- 
0.002 gm.). 

Physiologic Action and Therapeutics. — The domi- 
nant action of picrotoxin appears to be upon the centers in the 
medulla oblongata. In animals toxic doses produce violent 
clonic convulsions, acceleration of the respirations, slowing of 
the pulse, a marked rise in the arterial pressure, and vomiting. 
Death often results from asphyxia induced by the convulsive 
seizures. 

Picrotoxin has been recommended in a variety of conditions, 
but it is mainly useful in controlling the night-sweats of phthi- 
sis. The manner of its action is unknown ; but it may act 
indirectly, as Cushny suggests, by increasing the respirations 
and thus preventing the stimulant effect of partial asphyxia 
on the sweat-centers. As an antihydrotic it often succeeds 
when atropin and camphoric acid have failed. It is best 
given by the mouth, at bedtime, in the form of a pill or tablet. 

The tincture of Cocculus indicus (Anamirta paniculatd) is a 
reliable remedy for head lice. 

TELLURIUM. 

The most important tellurium compounds from a thera- 
peutic standpoint are the tellurates of sodium and potassium. 
These appear as white crystalline powders, soluble in water. 
The dose of either salt is from \— | gr. (0.02-0.05 gm.). 

Physiologic Action and Therapeutics. — In warm- 
blooded animals large doses of any one of the tellurium com- 
pounds cause vomiting, diarrhea, somnolence, weakening of 



266 EXPECTORANTS. 

the reflexes, paralysis, unconsciousness, respiratory failure, 
convulsions, and death. A characteristic feature of the poison- 
ing is the development of a strong garlicky odor in the breath 
a few minutes after the administration of the drug. This odor 
has been determined by Hofmeister to be due to the forma- 
tion of methyl tellurid. In man full doses of sodium or 
potassium tellurate arrest perspiration, impart an alliaceous 
odor to the breath, and impair slightly the digestion. Tellu- 
rium compounds undergo partial reduction in the body, and, 
according to Gies, are eliminated in the metallic form in the 
feces and as methyl tellurid in the breath, urine, feces, and epi- 
dermal secretions. As the antihydrotic action of tellurium is 
offset by pilocarpin (Czapek and Weil), it is probably due to 
depression of the peripheral secretory nerves. 

The tellurates have been recommended by Neusser, Combe- 
male, and Dubiquet, and others for their antihydrotic effects 
in advanced phthisis, but the garlicky odor of the breath, often 
persisting several weeks after treatment has been suspended, 
is a strong objection to their use. 

THALLII ACETAS. 

(Thallium Acetate ; T1C 2 H 3 2 .) 

Thallium acetate occurs in the form of white deliquescent 
crystals which are readily soluble in water and alcohol. The 
dose is from 1-3 gr. (0.065-0.2 gm.) in pills. 

Physiologic Action and Therapeutics. — Although 
thallium possesses decided toxic properties, these are not 
manifest when its salts are administered in therapeutic doses 
and for short periods. Combemale, Huchard, and others 
have found the acetate very effective in controlling the night- 
sweats of phthisis. Unfortunately, however, its continued use 
is not infrequently followed by alopecia. This untoward effect 
was observed in 8 of 34 cases in which Vossaux employed it 
as an antihydrotic. Huchard also has reported a case of total 
baldness following the administration of a dozen pills. The 
drug should be given about an hour before the expected 
sweating, and not repeated for more than four successive 
nights. 



EXPECTORANTS. 

Expectorants are drugs that modify the secretion of the 
air-passages, affect its quantity, and facilitate its expulsion. 
The exact manner of their action is obscure. Those that pro- 



EXPECTORANTS. 267 

mote secretion and render it less viscid in character, and, 
therefore, more easy of removal, are generally termed seda- 
tive expectorants. Most of the latter are also emetics, and, 
no doubt, owe their power of increasing secretion very 
largely to their nauseating properties. As a rule, they are 
employed as expectorants in much smaller doses than are 
required to produce vomiting, but occasionally vomiting itself 
renders valuable service in expelling mechanically excessive 
accumulations of tenacious mucus from the bronchi. The 
increased secretion which these drugs induce may be of ser- 
vice in depleting the congested bronchi, in protecting their 
surfaces from the air, in diluting and washing out the irritant, 
and, possibly, in exercising a bactericidal influence. The 
sedative expectorants in common use are : 

Ipecacuanha. Quebracho. 

Antimony (tartar emetic). Lobelia. 

Apomorphin. Potassium citrate. 

Sedative expectorants are indicated in acute bronchitis, par- 
ticularly in the early stage, when there is hard cough with 
little or no sputum. 

Drugs that stimulate the mucous membrane of the respira- 
tory tract and lessen the quantity of sputum are known as 
stimulant expectorants. Some of them appear to act by im- 
parting tone to the relaxed membrane, and others also by 
exercising an antiseptic influence on the secretions. The most 
important stimulant expectorants are : 

Ammonium chlorid. Sanguinaria. 

Ammonium carbonate. Garlic. 

Benzoin (benzoic acid). Grindelia. 

Balsam of Peru. Creosote (guaiacol). 

Balsam of tolu. Tar. 

Ammoniac. Squill. 

Eucalyptus. Oil of sandalwood. 

Oil of myrtle (myrtol). Copaiba. 

Senega. Cubeb. 

Oil of turpentine (terebene ; terpin hydrate). 

Stimulant expectorants are indicated in subacute and 
chronic bronchitis, especially when there is free expectoration. 

Adjuvants to Expectorants. — When cough is dispropor- 
tionate to expectoration and is in itself a source of distress, 
drugs may be combined with expectorants which lessen the ex- 
citability of the respiratory center or of the afferent and efferent 



268 EXPECTORANTS. 

nerves of lung. The most reliable drugs for this purpose are 
opium (morphin, codein, heroin), dilute hydrocyanic acid, chloro- 
form, bromids, hyoscyamus, and cannabis indica. Sometimes 
cough is dependent to a great extent upon excessive irritability 
of the fauces ; if this be the case, demulcents — licorice, gly- 
cerin, acacia — will be found useful adjuvants. When the 
respiratory center has become weakened through persistent 
cough, strychnin will prove beneficial. The same remedy also 
renders valuable aid when the pulmonary circulation is slug- 
gish, owing to insufficient cardiac power. When bronchial 
catarrh excites asthma, antispasmodics — belladonna, Hoff- 
mann's anodyne, chloroform, bromids — should be associated 
with expectorants. Lobelia is particularly useful in these 
cases, because it is both an expectorant and a depressomotor. 

Administration. — Expectorants, as a rule, are most 
effective when administered by the mouth. Sometimes, how- 
ever, inhalations act beneficially in allaying cough, facilitating 
expectoration, and lessening fetor of the breath. Except in 
the case of very volatile substances, it is doubtful whether 
vapors or sprays penetrate beyond the trachea and the main 
bronchial divisions. There are several methods of inhalation 
intended to influence the mucous membrane of the respira- 
tory tract. The simplest plan consists in breathing deeply 
the warm vapor arising from the surface of boiling water. 
For this purpose a volatile expectorant — compound tincture 
of benzoin, terebene, creosote — may be dropped into a wide- 
mouthed jug nearly filled with hot water, and the vapor con- 
ducted to the nose and mouth through a cone made of stiff 
paper or a folded napkin. Inhalations of this class are rarely 
useful, except in acute bronchitis. More complicated, but 
somewhat more serviceable, are the various hand-ball and 
steam 'atomizers designed to reduce medicated fluids to a 
nebular form. In chronic bronchitis the cold spray has an 
advantage over the steam spray in being less relaxing in its 
effect on the throat and trachea. 

Another method of administering medicated vapors is by 
the so-called respirator. One of the most useful of the latter 
contrivances is the oronasal respirator devised by Dr. Burney 
Yeo, which consists of a perforated zinc mask, shaped to fit 
over the nose and mouth, and held in position by tapes passed 
around the ears. This mask incloses a sponge which is 
charged from time to time with the volatile inhalant. Creosote 
(with an equal amount of spirit of chloroform), turpentine, tere- 
bene, eucalyptol, and menthol are the drugs most frequently 
used in the respirator. 



IPECACUANHA. 269 

The intralaryngeal injection of drugs into the trachea some- 
times affords great relief in chronic bronchitis, in bronchi- 
ectasis, and even in phthisis. If they are skilfully made, they 
rarely excite cough or other discomfort. Some bland oil, like 
olive oil, is usually made the vehicle for the active drug — 
guaiacol (1 : 100 or 1 : 50) or menthol (1 : 50). 

SEDATIVE EXPECTORANTS. 
IPECACUANHA, U. S. P. 

(Ipecac.) 

Ipecac is the root of Cephaelis Ipecacuanha, or of Cephaelis 
acuminata, a perennial shrub growing in Brazil and other South 
American States. According to Paul and Cownley, it contains 
three alkaloids — emetin, cephaelin, and psychotrin. The does 
of the powdered drug as an expectorant is from J-2 gr. (0.03- 
O.13 gm.) ; as an emetic, 15-30 gr. (1.0-2.0 gm.). 

Preparations. Dose. 

Fluidextractum Ipecacuanha, U. S. P As an expectorant 2-5 nun- 

(0.I-0.3 c.c.) ; as an eme- 
tic, 15-30 min. (1.0-2.0 
c.c). 

Syrupus Ipecacuanhae, U. S. P. As an expectorant, 10-60 

min. (0.6-4.0 c.c.) ; as an 
emetic, 2-4 fl. dr. (8.0- 
15.0 c.c). 

Vinum Ipecacuanhae, U. S. P As an expectorant, 10-60 

min. (0.6-4.0 c.c) ; as an 
emetic, 2-4 fl. dr. (8.0- 
15.0 c.c). 
Tinctura Ipecacuanha et Opii, U. S. P. ( I gr. — 
0.065 gm. — each of ipecac and powdered 

opium in 10 min. — 0.6 c.c.) 5-15 min. (0.3-I.0 c.c). 

Pulvis Ipecacuanhae et Opii, U. S. P. (Dover's 
powder: ipecac, I part; powdered opium, I 

part; sugar of milk, 8 parts) 5-iO gr. (0.3-0.6 gm.). 

Pilulre Laxativse Compositse, U. S. P. (each pill 
contains aloin,^ gr. (0.013 gm.) ; strychnin, 
y£ f gr. (0.0005 g™- > extract of belladonna, 
\ gr. (0.008 gm. ; ipecac, ^ gr. (0.004 gm.); 
with licorice and syrup 1-3 pills. 

Physiologic Action. — Ipecac is a powerful local irritant. 
When rubbed into the skin it causes erythema and vesication ; 
when applied to mucous membranes it produces redness, 
swelling, and an increase of secretions. In some persons the 
mucous membrane of the respiratory tract is so sensitive to 
the drug that the inhalation of an exceedingly small quantity 
of the powder is sufficient to excite lacrimation, sneezing, run- 



270 EXPECTORANTS. 

ning from the nose, and asthmatic breathing. The ingestion 
of a full dose of ipecac is followed in a short time by nausea, 
vomiting, and a marked increase of the secretions of the nose, 
mouth, and bronchi. These effects are due to cephaelin and 
emetin. Both alkaloids are active emetics, but the former is 
decidedly more powerful in this respect than the latter. The 
emesis is probably of peripheral origin, though the drug is 
believed by some writers to act also on the vomiting center in 
the medulla. 

The subcutaneous injection of a toxic dose of emetin is 
followed by nausea, vomiting, purging, and collapse. It is 
well-established clinically that small doses of ipecac promote 
both the cutaneous and bronchial secretions. 

Therapeutics. — Ipecac is chiefly employed as a sedative 
expectorant, an emetic, an anti-emetic, an antidysenteric, and a 
diaphoretic. 

Expectorant. — Ipecac is an excellent expectorant in acute 
bronchitis before secretion has been established. In chronic 
bronchitis, when the sputum is scanty and viscid, it is also ser- 
viceable. In the form of a spray the wine, diluted with twice 
its bulk of water, as recommended by Murrell, is often very 
efficacious in " winter cough " and bronchial asthma. 

Emetic. — Ipecac, though not very prompt in its action, is 
a certain and safe emetic. It is especially useful in children, 
in whom it is frequently employed to unload the stomach of 
irritant material. In capillary bronchitis, when the bronchi 
become filled with mucus and asphyxia is threatened, ipecac 
may be given in doses sufficient to excite emesis, with the 
hope of forcibly expelling the secretion. In poisoning more 
prompt emetics, like apomorphin or zinc sulphate, are pre- 
ferable. 

Anti-emetic. — Ipecac in minute doses sometimes succeeds 
in controlling persistent vomiting that is not dependent upon 
any organic disease of the stomach. The wine is the best 
preparation; it should be given in doses of from J— I minim 
(0.03-0.06 c.c.) every half-hour or hour. In some instances 
its efficacy is enhanced by the addition of an equal quantity of 
the tincture of nux vomica. 

Antidysenteric. — Ipecac has a long-standing reputation in 
acute tropical dysentery ; a large dose of from 30-40 gr. (2.0- 
2.6 gm.) should first be given to induce vomiting, and after 
this has occurred smaller doses of from 3-5 gr. (0.2-0.3 gm.) 
should be given at intervals of two hours. To insure the re- 
tention of the latter doses, 5 min. (0.3 c.c.) of laudanum may 
be administered fifteen minutes before each dose of ipecac. A 



ANTIMONII ET POTASSII TARTRAS. 2J\ 

successful result is usually indicated by the appearance within 
twelve hours of copious tarry stools. In the sporadic dysen- 
tery of temperate zones this treatment is of little value. 

Diaphoretic. — The mild and agreeable diaphoretic effect 
of ipecac in the form of Dover's powder has made the latter a 
favorite remedy in the initial stage of acute coryza, in so-called 
muscular rheumatism, in influenza, and in acute suppression of 
the menses. 

Other Uses. — Ipecac has been recommended as a hemo- 
static since Trousseau's time, but its use in hemorrhage is at 
present obsolescent. Rutherford and Vignal concluded, from 
their experiments on dogs, that ipecac is a direct hepatic 
stimulant, but the work of other investigators has served to 
throw considerable doubt on this conclusion. In minute 
doses (-|— \ gr. — 0.008-0.016 gm.) it is an excellent adjuvant to 
strychnin in indigestion dependent upon motor insufficiency. In 
atony of the bowel, also, it often makes a useful addition to 
cathartic pills. 

Administration.— For producing emesis either the wine 
or the syrup may be selected ; in children the syrup, \- 2 fl. dr. 
(2.0-8.0 c.c.), is preferable. Paul and Cownley recommend 
cephaelin as a powerful and certain emetic, free from depress- 
ing effects when given in doses of from ^ - I gr. (0.006-0.01 
gm.), but it is too costly for ordinary use. The preparations 
and alkaloids of ipecac are all too irritating to be administered 
hypodermically. As an expectorant the wine, 'syrup, or fluid 
extract may be employed. A combination of ipecac with an 
alkaline expectorant, as in the following formula, is often 
effective in the first stage of bronchitis : 

R Vini ipecacuanha, fgiiss ( 10.0 c.c.) ; 

Potassii citratis, giij (12.0 gm.); 

Tincturse opii camphoratee, 

Syrupi acaciee, aa £f j (30.0 c.c.) ; 

Aquae, q. s. ad f^vj (180.0 c.c). — M. 

Sig. A tablespoonful every four hours. 

ANTIMONII ET POTASSII TARTRAS, U. S. P. 

(Tartar Emetic; (KSbOC t H 4 6 ) 2 -f H 2 0.) 

Tartar emetic is the only official preparation of antimony. 
It occurs in the form of colorless crystals or a white granular 
powder, having a sweetish metallic taste, soluble in 15.5 parts of 
cold water and insoluble in alcohol. The dose as an expectorant 
is 2 a o - 4" S r - (0.003-0.008 gm.) ; as an emetic, J-i gr. (0.03-0.06 
gm.). 



272 EXPE CTO RANTS. 

Preparations. Dose. 

Vinum Antiraonii, U. S. P. (4 parts of tartar 

emetic in 1000). 

As an expectorant 10-20 min. (0.6-1.2 c.c). 

As an emetic 1-4 fl. dr. (4.0-15.0 c. c. ). 

Syrupus Scillse Compositus, U. S. P. (0.2 

percent, with squill and senega). . . . 5-60 min. (0.3-4.0 c.c. ). 

Tartar emetic is also contained in compound licorice mixture. 

Physiologic Action. — Save that it is more irritant and is 
absorbed with greater difficulty, tartar emetic, like other anti- 
monial preparations, has an action similar to that of arsenic. 
When applied to the skin in ointment it produces papules, 
vesicles, pustules, and, if the contact be prolonged, diffuse ab- 
scesses. Taken internally in small doses (J- \ gr. — 0.008-0.016 
gm.) it causes nausea and some increase in the perspiration and 
secretions of the mouth and respiratory tract. Large doses (1-2 
gr. — 0.065-0.13 gm.) produce persistent vomiting with saliva- 
tion, copious sweating, and marked depression. Still larger 
doses are followed by choleraic discharges from the bowel, 
painful cramps, and collapse. 

The emesis occasioned by tartar emetic is probably the result 
of the direct irritant action of the drug on the stomach, though 
some writers believe that it is partly of cerebral origin. The 
marked depression and ultimate collapse after large doses are 
due partly to the violent emesis, partly to paralysis of the 
vessels of the splanchnic area, and partly to weakening of the 
heart itself. In fatal poisoning postmortem examination reveals 
intense congestion of the alimentary canal with hemorrhagic 
extravasations, and also cloudy swelling and fatty degeneration 
of the parenchymatous organs. Antimony is excreted chiefly 
by the stomach and bowel, but in small part by the kidneys, 
skin, and respiratory tract. 

The treatment of a ntimonial poisoning consists in the adminis- 
tration of tannin to form an insoluble salt, in washing out the 
stomach, and in combating collapse with diffusible stimulants 
and external heat. 

Therapeutics. — Tartar emetic is an efficient expectorant 
in acute bronchitis when there is hard cough with little or no 
expectoration. It may be prescribed conveniently in the form 
of wine of antimony, as in the following formulae : 

Bt Vini antimonii, fgij (8.0 c.c.) ; 

Spiritus setheris nitrosi, rfj (30.0 c.c.) ; 

Tincturse opii camphoratse, f^ ss ( r 5-° c.c.) ; 

Liquoris potassii citratis, q. s. ad fjiv (120.0 c.c). — M. 

Sig. A dessertspoonful in water every two or three hours. 



APOMORPHIN^ HYDROCHLORIDUM. 273 

R Vini antimonii, TTl x l (2.5 c.c.) ; 

Syrupi tolutani, f^j (30.0 c.c.) ; 

Liquoris ammonii acetatis, q. s. adfgiij (90.0 c.c). — M. 

Sig. A teaspoonful eveiy two hours for a child of two years. 

Tartar emetic was formerly used also as an emetic, a dia- 
phoretic, circulatory depressant, and counterirritant, but for 
these purposes it has been almost entirely displaced by other 
and less poisonous remedies. 

Incompatibles. — Tartar emetic is incompatible with tannic 
acid, mineral acid, alkaline carbonates, and lime water. 

APOMORPHIN^ HYDROCHLORIDUM, U. S. P. 

(Apomorphin Hydrochlorid.) 

Apomorphin is an artificial alkaloid obtained by abstracting 
from morphin a molecule of water. It is prepared by main- 
taining at a high temperature for several hours, in a sealed 
retort, a mixture (1 : 20) of morphin and strong hydrochloric 
acid. The hydrochlorid of this alkaloid appears as minute 
grayish- white, acicular crystals, having a faintly bitter taste, and 
acquiring a greenish tint on exposure to light and air. It is 
soluble in about 40 parts of water or alcohol. The dose as 
an expectorant is from ^V~ 2V § r - (0-002-0.003 gm.) ; as an 
emetic, from ^ \ gr. (0.005-0.01 gm.). 

Physiologic Action. — In man the subcutaneous injection 
of 3^- gr. (0.006 gm.) of apomorphin is followed within fifteen 
minutes by nausea and vomiting. The emesis is accom- 
panied by muscular relaxation, quickening of the pulse, free 
perspiration, and a marked increase in the nasal, faucial, and 
bronchial secretions. The vomiting is of centric origin. 

On the central nervous system apomorphin appears to have 
first a stimulant, and then a paralyzant, effect. The heart is 
not influenced by therapeutic doses, but toxic doses induce 
paralysis. The rapid pulse observed after emetic doses is due, 
according to Reichert, to stimulation of the accelerators. 

Therapeutics. — Apomorphin is employed as an emetic 
and as a sedative expectorant. 

Emetic (see p. 166). — The certainty and promptness of its 
action and its freedom from irritant properties when adminis- 
tered hypodermically make it almost an ideal emetic in poison- 
ing, especially when swallowing is impossible or the state of 
the stomach is such as to forbid the use of emetics having a 
peripheral action. In young children and infirm subjects con- 
siderable caution must be exercised in its employment, since 
its action may be attended with profound exhaustion or even 
collapse. 

18 



274 EXPECTORANTS. 

Expectorant. — Apomorphin is a useful expectorant in both 
acute and chronic bronchitis, when the sputum is scanty and 
viscid. As it is eliminated rather rapidly, it should be given 
at comparatively short intervals — that is, every two or three 
hours. Apomorphin in small doses (g 1 -^ gr. — 0.002 gm.) has 
also some soporific effect for which it has been especially 
recommended in delirium tremens. 

Administration. — As an emetic apomorphin should be 
administered hypodermically. Solutions can be conveniently 
prepared from tablets containing the requisite dose. Both 
tablets and solution are liable to deteriorate with age and on 
exposure to light and air. As an expectorant it should be 
given by the mouth in the form of a solution, pill, or capsule. 

Incompatibles. — Alkalis, potassium iodid and ferric chlo- 
rid. It is said to be incompatible also with heroin. 

Apocodein Hydrochlorid. — This compound is prepared 
from codein after the manner of preparing apomorphin from 
morphin. It is an amorphous, yellow powder, soluble in water 
and alcohol. It has been recommended chiefly as an expecto- 
rant, in doses of from |—i gr. (0.05-0.065 gm.). 

ASPIDOSPERMA. 

(Quebracho.) 

Quebracho is the bark of Aspidosperma Quebracho-bianco, 
an evergreen tree growing in South America. It contains 
several alkaloids, the most important of which is aspidospermin. 
The aspidospermin of commerce, however; is really a mixture 
of the various alkaloids, and may be given in doses of from 
}-l gr. (0.03-0.065 gm.). 

Preparation. Dose. 

Fluidextractum Aspidospermatis 20-60 min. (1.2-4.0 c.c). 

Physiologic Action and Therapeutics. — Several of the 
alkaloids of quebracho resemble apomorphin in their action in 
that they first stimulate and then depress the central nervous 
system. Like apomorphin also they induce nausea and in- 
crease the secretions of the throat and bronchi. Only one alka- 
loid, however, is an active emetic, and that is aspidosamin. 
Aspidospermin in small dose is apparently an active respira- 
tory stimulant. 

Because of its influence on respiration and bronchial secre- 
tion quebracho has been found useful in bronchitis associated 
with asthma or emphysema. 



STIMULANT EXPECTORANTS. 2J$ 

OTHER SEDATIVE EXPECTORANTS, 

I,obelia (see p. 151). — Lobelia, like other nauseants, in- 
creases the bronchial secretions. In large dose it also de- 
presses the fibers of the vagus distributed to the bronchial 
muscles. Owing to this combined action, the drug is espe- 
cially valuable in bronchitis with asthma. The dose of the 
tincture of lobelia as an expectorant is from 10-30 min. (0.6- 
2.0 c.c.); of the fluid extract, from 2-5 min. (0.1-O.3 c.c). 

Potassium Citrate (see p. 228). — This and other vegetable 
salts of potassium are useful expectorants in the early stages of 
acute bronchitis. The citrate is generally preferred to the other 
salts, owing to its less unpleasant taste. It may be prescribed 
in doses of from 20-30 gr. (1.3-2.0 gm.), in combination with 
a nauseant like ipecac or antimony. 

STIMULANT EXPECTORANTS. 
AMMONII CHLORIDUM, U. S. P. 

(Ammonium Chlorid ; Sal Ammoniac; NH 4 C1.) 

Ammonium chlorid is a white crystalline powder, odorless, 
of a cooling, saline taste, and permanent in the air. It is solu- 
ble in 2 parts of cold water and in 50 parts of alcohol. The 
dose is from 5-20 gr. (0.3-1.3 gm.). 

Preparation. 
Trochisci Ammonii Chloridi, U. S. P. (each contains ammonium chlorid, l\ 
gr. — O.I gm. ; licorice extract, 3 gr. — 0.2 gm.; with tragacanth, sugar, 
and syrup of tolu). 

Physiologic Action. — The chief effect of ammonium 
chlorid when administered by the mouth in moderate doses is 
to increase and render less viscid the mucous secretion of the 
bronchi, and perhaps, also, of the stomach and bowel. While 
it lacks the stimulant influence of ammonium carbonate on the 
circulation and respiration, its action on the mucous membranes 
is much more prolonged than that of the latter salt. Very 
large doses have an irritant action and excite the symptoms of 
gastro-enteritis. Blood dyscrasia with great muscular weak- 
ness has been observed after the prolonged use of ammonium 
salts in large doses. Ammonium chlorid is eliminated in the 
urine for the most part unchanged. 

Therapeutics. — Ammonium chlorid is particularly useful 
as an expectorant in acute bronchial catarrh after the symptoms 
of the initial stage have passed. It is sometimes successfully 
employed also in chronic bronchitis when the sputum is chiefly 
thick, tenacious mucus. In subacute and chronic pharyngitis 
or laryngitis lozenges of ammonium chlorid or a warm spray 



276 EXPECTORANTS. 

of the salt (5 gr.-i oz. — 0.3 gm.-30.o c.c.) may prove bene- 
ficial. The drug has found favor with some practitioners in 
subacute gastro-intestinal catarrh and in catarrhal jaundice. 

A solution of ammonium chlorid — 5 gr. (0.3 gm.) to \ 
ounce (15.0 c.c.) each of alcohol and water — makes an excel- 
lent lotion in contusions with much ecchymosis. 

Administration. — The drug is generally given in aqueous 
solution to which licorice is added to disguise its unpleasant 
salty taste. It may also be prescribed in the form of com- 
pressed tablets to be taken after meals in several ounces of 
water : 

R Ammonii chloridi, ^iiss (10.0 gm.) ; 

Syrapi scillse, f^v (18.5 c.c.) ; 

Tincturse opii deodorati, TT\, xl (2.5 c.c.) ; 

Extracti glycyrrhizae, gj (4.0 gm.) ; 

Glycerini, fjss (15.0 c.c); 

Aquae, q. s. ad f^iv (120.0 c.c). — M. 
Sig. A dessertspoonful in water four times a day. 

In chronic bronchitis with inspissated secretions an iodid 
may be combined with ammonium chlorid, as in the following 
formula : 

R Ammonii iodidi, £ss (2.0 gm.) ; 

Ammonii chloridi, ^ij (8.0 gm.); 

Syrupi pruni Virginianae, f§ij (60.0 c.c.) ; 

Aquas, q. s. ad fjiv (120.0 c.c). — M. 

Sig. A dessertspoonful in water every four hours. 

Incompatibles. — Alkalis, mineral acids, tartaric acid, and 
soluble salts of silver and lead. 

AMMONII CARBONAS, U. S. P. 

(Ammonium Carbonate ; NH 4 HC0 3 . NH 4 NH 2 C0 2 .) 

The ammonium carbonate of commerce is a mixture of am- 
monium bicarbonate (acid carbonate) and ammonium carbam- 
ate. It occurs in white, translucent masses having a strong 
ammoniacal odor and a sharp saline taste. It is soluble in 
about 4 parts of cold water, and is decomposed by boiling 
water, with the elimination of carbon dioxid and ammonia. 
On exposure to air it is converted into an opaque white pow- 
der of ammonium bicarbonate. The dose is from 5-10 gr. 
(0.3-0.8 gm.). 

Preparation. Dose. 

Spiritus Ammonise Aromaticus, U. S. P. (am- 
monium carbonate, 3.4; ammonia water, 9; 
aromatic oils; water to make 100 parts) . . 20-60 min. (1.0-4.0 c.c). 



BENZOINUM. 277 

Physiologic Action. — In therapeutic doses ammonium 
carbonate acts as a circulatory stimulant, a respiratory stim- 
ulant, and an expectorant. Its action is prompt, but evanescent. 
In large doses it is an irritant and capable of provoking emesis. 
It is eliminated in the urine as urea. 

Therapeutics. — Ammonium carbonate may be substituted 
for the water or one of the spirits of ammonia in combatting 
syncope, collapse, and other forms of sudden heart failure. As 
a stimulant expectorant it is especially useful in bronchitis as- 
sociated with cardiac or respiratory weakness. In pneumonia, 
both croupous and catarrhal, it often acts beneficially in facili- 
tating expectoration and in stimulating the circulation. In 
pulmonary emphysema, when the dyspnea and cyanosis are 
greatly exaggerated by attacks of acute bronchial catarrh, it 
acts admirably in conjunction with strychnin and digitalis. 

Mixed with half its bulk of stronger water of ammonia and 
scented, it constitutes the " smelling-salts," a popular remedy 
for syncope. 

Administration. — On account of the rapidity with which 
ammonium carbonate is decomposed after absorption it is 
necessary, to secure the desired effect, to administer it at inter- 
vals of not more than two hours. It is always given in 
solution, the favorite vehicle being syrup of acacia. 

Incompatibles. — It is incompatible with acids, acid salts, 
alkaloidal salts, and ferric salts. 

BENZOINUM, U. S. P. 

(Benzoin; Gum Benzoin.) 

Benzoin is a balsamic resin obtained from Styrax Benzoin, 
a large tree growing in Sumatra, Java, Borneo, and Siam. It 
contains several resins, benzoic acid (15-20 per cent), a vola- 
tile oil, cinnamic acid, and vanillin. It is soluble in about 5 
parts of warm alcohol and in solutions of the fixed alkalis. 
Benzoic acid is soluble in 2 parts of alcohol and very spar- 
ingly soluble in water. The salts of benzoic acid — ammonium, 
lithium, and sodium — are readily soluble in water. 

Preparations. Dose. 

Tinctura Benzoini, U. S. P 20-60 min. ( 1. 2-4.0 c.c). 

Tinctura Benzoini Composita, U. S. P. 

(Friar's or Turlington's Balsam : 10 per 

cent., with aloes, tolu, and storax) . . . 20-60 min. (1.2-4.0 c.c). 
Adeps Benzoinatus, U. S. P. (2 per cent.). 

Acidum Benzoicum, U. S. P 5-20 gr. (0.3-1.3 gm.). 

Ammonii Benzoas, U. S. P 5~3° g r « (0.3-2.0 gm.). 

Lithii Benzoas, U. S. P 5-30 gr. (0.3-2.0 gm.). 

Sodii Benzoas, U. S. P S~3° S r ' (0.3-2.0 gm.). 



278 EXPECTORANTS. 

Benzoic acid (0.4 per cent.) also enters into camphorated 
tincture of opium, or paregoric. 

Physiologic Action. — Benzoic acid is an antiseptic of 
considerable power and a stimulant to the mucous membranes. 
In health moderate doses do not affect the functions of the 
body beyond increasing, to a variable degree, the nitrogenous 
output and lessening the quantity of ethereal sulphates and of 
indican in the urine. It escapes from the body rapidly, chiefly 
through the kidneys, and for the most part in the form of hip- 
puric acid — a compound of benzoic acid with the proteid 
derivative, glycocoll. It is generally believed that benzoic 
acid increases the acidity of the urine, but according to W. W. 
Ashhurst, who has investigated the subject very carefully, 
sodium benzoate, at least, has little or no influence on the 
acidity of urine that is already acid, but that it does render al- 
kaline urine acid ; not so much by its presence, however, as by 
its power of arresting ammoniacal fermentation. In large 
doses benzoic acid and benzoates have an irritant action on 
the stomach, and in consequence excite nausea and vomiting. 

Therapeutics. — The compound tincture of benzoin painted 
over the part and allowed to dry is a useful protectant for 
small wounds. A combination of the compound tincture with 
4 parts of glycerin makes an efficient application in chapped 
nipples, hands, or lips. A dram (4.0 c.c.) to a pint (0.5 L.) of 
boiling water may be used as an inhalant in acute laryngitis 
and bronchitis. The tincture may be prescribed internally 
also in subacute and chronic bronchitis when expectoration is 
very viscid. Benzoic acid itself often affords prompt relief in 
phosphaturia, and in cystitis with ammoniacal urine. Sodium 
benzoate, in doses of from 5-10 gr. (0.3-0.6 gm.), is a very 
useful remedy in acute pharyngitis and tonsillitis. 

Owing to the fact that benzoic acid is eliminated as the 
soluble hippuric acid, it was hoped that the benzoates would 
prove of value in gout, but experience has shown that they 
are of no avail. Senator and others have recommended the 
benzoates in rheumatism, but they have been found to be far 
less efficacious than the salicylates. 

The treatment of phthisis by intravenous injections of cin- 
namic acid (see p. 190), so highly recommended by Landerer, 
is very painful and does not seem to have given any better 
results than can be obtained by other means. 

Administration. — Benzoic acid is best administered in 
capsules or pills. The benzoates may be administered in solu- 
tion or in powders. The tinctures are incompatible with aque- 
ous preparations. 



BALSAMUM TQLUTANUM. 279 

BALSAMUM PERUVIANUM, U. S. P. 

(Balsam of Peru.) 

Balsam of Peru is a brownish-black, syrupy liquid, obtained 
by bruising the bark of Toluifera Pereira, a large tree growing 
in Central America. It has a smoky, vanilla-like odor and a 
bitter, persistent taste. It is soluble in alcohol, chloroform, 
and glacial acetic acid. It contains resins, cinnamic and ben- 
zoic acids, and traces of vanillin. The dose is from 5-30 min. 
(0.3-2.0 c.c). 

Therapeutics. — Balsam of Peru is chiefly employed as a 
protectant and parasiticide. It was at one time used as a 
stimulant expectorant in chronic bronchitis, but it has been 
entirely replaced by more elegant remedies. It is still occa- 
sionally employed as a stimulant protectant dressing in bed- 
sores and other ulcers. Alone, or in combination with sulphur, 
it is a reliable remedy in scabies, in which disease it may be 
prescribed as follows : 

R Sulphuris prsecipitati, 

Balsami Peruviani, aa gij (8.0 gm.) ; 

Olei olivse, f^ss (15.0 c.c); 

Adipis, q. s. ad ^ij (60.0 gm.). — M. 

BALSAMUM TOLUTANUM, U. S. P. 

(Balsam of Tolu.) 

Balsam of tolu is a yellowish-brown, semiliquid mass, 
obtained by incising the bark of Toluifera Balsamum, an ever- 
green tree growing in South America. It has a vanilla-like 
odor and a mild, aromatic taste, and is soluble in alcohol, 
ether, and chloroform, but is insoluble in water. It contains 
resin, a volatile oil, vanillin, and cinnamic and benzoic acids. 
The dose is from 5-30 gr. (0.3-2.0 gm.). 

Preparations. Dose. 

Syrupus Tolutanus, U. S. P 1-4 fl. dr. (4.0-15.0 c.c). 

Tinctura Tolutana, U. S. P £-1 fl. dr. (2.0-4.0 c.c). 

fin crura Benzoini Composita, U. S. P. (4 
percent.) 20-60 min. (1.2-4.0 c.c). 

Therapeutics. — Balsam of tolu has but feeble medicinal 
properties. It is chiefly employed on account of its agreeable 
flavor as a vehicle in cough-mixtures. 



280 EXPECTORANTS. 

AMMONIACUM. 

(Ammoniac.) 

Ammoniac is a gum-resin obtained by puncturing the stems 
of Dorema Afnmoniacum, a plant growing in Persia and Tur- 
kestan. The dose is from 10-30 gr. (0.65-2.0 gm.). 

Therapeutics. — Ammoniac was once much used as a 
stimulant expectorant and a counterirritant, but it has been 
largely superseded by more efficient remedies. 

EUCALYPTUS, U. S. P. 

Eucalyptus is the leaves of Eucalyptus Globulus, or gum-tree, 
a native of Australia, and cultivated in Europe and Southern 
United States. It contains a volatile oil (6 per cent.), from 
which is obtained a neutral body, eticalyptol. The latter is a 
colorless liquid, having a camphoraceous odor and a pungent, 
spicy taste, and on exposure to a temperature below 30 F. 
solidifying into a mass of needle-shaped crystals. It is in- 
soluble in water, but freely so in alcohol. 

Preparations. Dose. 

Fluidextractum Eucalypti, U. S. P. ... 20-60 min. (1.2-4.0 c.c). 

Oleum Eucalypti, U. S. P 3-10 (0.2-0.6 c.c). 

Eucalyptol, U. S. P 3-10 (0.2-0.6 c.c). 

Eucalyptol also enters into the official antiseptic solution 
(Liquor Antisepticus). 

Physiologic Action. — Oil of eucalyptus is a local irritant. 
When applied to the skin, evaporation being prevented, it causes 
redness and even vesication. When taken internally in large 
doses (20 min. — 1.2 c.c), it causes a sense of burning in the 
throat and stomach, nausea, looseness of the bowels, and some 
mental exhilaration, which in turn is followed by a feeling of 
calm. Toxic doses depress the spinal cord, medulla, and 
heart, and in consequence induce extreme muscular weakness, 
a fall of temperature, a feeble pulse, shallow respiration, and 
finally death from asphyxia. The drug is eliminated by all 
the emunctories, and, like turpentine, it imparts the odor of 
violets to the urine. 

Both eucalyptol and the oil have pronounced antiseptic 
properties. 

Therapeutics. — Eucalyptus was at one time used as a sub- 
stitute for quinin in malaria, but its value in this disease was 



OLEUM MYRTI— SENEGA. 28 1 

never established, and to-day it is rarely, if ever, employed. In 
subacute and chronic bronchitis attended with copious expecto- 
ration the oil is an exceedingly useful expectorant. As an 
inhalant, also, oil of eucalyptus is sometimes efficacious in 
diminishing profuse expectoration in bronchiectasis and phthisis. 
A dram (4.0 c.c.) may be added to an ounce (30.0 c.c.) of 
liquid petrolatum and used in an atomizer; or eucalyptol 
alone or in conjunction with terebene may be used in an 
inhalation respirator. 

Eucalyptol in the form of an oily spray acts very favorably in 
subacute and chronic rhinitis, if used after the nares have been 
thoroughly cleansed with an alkaline wash. The following 
formula, suggested by Douglass, is an excellent one : 

JJ Thymol, gr. x (0.65 gm.) ; 

Menthol, gr. xx (1.3 gm.) ; 

Eucalyptol, gtt. xx (0.6 c.c.) ; 

Olei cubebse, gtt. xl (1.2 c.c); 

Benzoinol, f|yj (175.0 c.c). — M. 

Oil of eucalyptus is sometimes used as a urinary antiseptic in 
cystitis and urethritis. 

Administration. — The oil and eucalyptol are the best 
preparations for internal use. They may be given on sugar, 
in capsules, or in an emulsion. 



OLEUM MYRTI. 

(Oil of Myrtle ; Myrtol.) 

Oil of myrtle is a greenish-yellow, volatile oil, distilled from 
the leaves and flowers of Myrtus communis, the common Eu- 
ropean myrtle. It has properties almost identical with those 
of eucalyptol. The dose is from 3-10 min. (0.2-0.6 c.c). It 
is an excellent stimulant expectorant in bronchorrhea, bronchi- 
ectasis, and fibroid phthisis. Eichhorst has used it with satis- 
faction in pulmonary gangrene. 

SENEGA, U. S. P. 

Senega is the root of Polygala Senega, a perennial herb 
growing in woody places in North America. It contains a 
white, amorphous body — senegin — belonging to the saponin 
group of glucosids. 



282 EXPECTORANTS 

Preparations. Dose. 

Fluidextractum Senegae, U. S. P 5-20 min. (0.3-1.2 c.c. V 

Syrupus Senega, U. S. P \-z fl. dr. (2.0-8.0 c.c). 

Syrupus Scillae Compositus, U. S. P. (fl. 

ext. of squill, 8 per cent. ; fl. ext. of 

senega, 8 per cent. ; tartar emetic, 0.2 per 

cent.) 10-60 min. (0.6-4.0 c.c). 

Physiologic Action and Therapeutics. — Senega is a 
local irritant and emetic. It is chiefly used, however, as a 
stimulant expectorant in subacute and chronic bronchitis with 
copious expectoration. It is often prescribed in combination 
with squill. 

SANGUINARIA, U. S. P. 

(Bloodroot.) 

Sanguinaria is the rhizome of Sanguinaria canadensis, a 
perennial herb growing in the woods of North America. It 
contains an alkaloid, sanguinarin. 

Preparations. Dose. 

Tinctura Sanguinariae, U. S. P IO-30 min. (0.6-2.0 c.c). 

Fluidextractum Sanguinariae, U. S. P. . . 1-5 min. (0.06-0.3 c.c). 

Physiologic Action and Therapeutics. — Sanguinaria 
is a powerful irritant. In large doses it excites nausea and 
vomiting. Toxic doses of sanguinarin cause salivation, violent 
intestinal peristalsis, spinal convulsions, and, finally, cardiac 
and respiratory failure. Sanguinaria has been employed as an 
emetic and a stimulant expectorant, but it is now mostly re- 
placed by more efficient and less dangerous drugs. 

ALLIUM. 

(Garlic) 

Garlic is the fresh bulb of Allium sativum, a plant indigen- 
ous to Southern Europe and cultivated in North America. Its 
active principle is a volatile oil. 

Preparation. Dose. 

Syrupus Allii 1-4 fl. dr. (4.0-15.0 c.c). 

Therapeutics. — Garlic was at one time a favorite stimulant 
expectorant, especially for children ; it has been superseded, 
however, by more agreeable remedies. 



CREOSOTUM. 283 

GRINDELIA, U. S. P. 

Grindelia is the leaves and flowering tops of Grindelia 
robusta and Grindelia squarrosa, perennial herbs growing in 
North America, west of the Rocky Mountains. It contains 
resin, a bitter principle, and a volatile oil of a terebinthinate 

odor. 

Preparation. Dose. 

Fluidextractum Grindeliae, U. S. P. . . . 15-60 min. (1.0-4.0 c.c). 

Therapeutics. — Grindelia is a very useful remedy in 
bronchitis complicated with asthma. It may be prescribed 
alone or in combination with other antiasthmatics, as in the 
following formula : 

R Sodii iodidi, zj (4.0 gm.) ; 

Fluidextracti grindelise, fgss (15.0 c.c.) ; 

Tincturse lobelioe, 

Tincturae belladonnae, aa fz,ij (8.0 c.c.) ; 

Fluidextracti glycyrrhizse, fzjij (u.oc.c); 

Syrupi tolutani, q. s. ad f^iij (90.0 c.c). — M. 
Sig. A teaspoonful every three or four hours. 

The fumes of burning grindelia leaves are also efficacious 
in allaying the cough and relieving the dyspnea of asthma. A 
lotion consisting of an ounce (30.0 c.c.) of the fluid extract to 
a pint of water (0.5 L.) has been highly recommended in rhus 
poisoning and erysipelas. It should be applied on cloths and 
allowed to evaporate. 

CREOSOTUM, U. S. P. 

(Creosote.) 

Creosote is a mixture of phenols, chiefly guaiacol and 
creosol, obtained during the distillation of wood-tar, preferably 
of that derived from the beech. It is a colorless or faintly 
yellow, oily liquid, having a penetrating, smoky odor and a 
burning, caustic taste. It is soluble in 150 parts of water, and 
in all proportions in alcohol, ether, chloroform, and oils. 
Much of the creosote of commerce is impure carbolic acid. 
Notable quantities of the latter, however, may be detected by 
one of the following tests : first, by the formation of a coagu- 
lum when equal quantities of the suspected liquid and collo- 
dion are mixed in a dry test-tube, and, secondly, by the 
absence of turbidity when one or more volumes of water are 
added to an intimate mixture of equal volumes of the liquid 
and glycerin. The dose of creosote is from 1-10 min. (0.06- 
0.6 c.c), gradually increased to the limit of tolerance. 



284 EXPECTORANTS. 

Preparation. Dose. 

Aqua Creosoti, U. S. P. (about 1 per cent.) 1-4 fl. dr. (4.0-15.0 c.c). 

Physiologic Action. — The action of creosote closely 
resembles that of carbolic acid, but it is much less irritant and 
toxic. Very large doses, however, produce all the symptoms 
commonly observed in carbolic-acid poisoning — namely, burn- 
ing pain, nausea and vomiting, vertigo, collapse, and almost 
simultaneous failure of the heart and respiration. As pointed 
out by Hare, soluble sulphates — Epsom or Glauber salts — are 
chemical antidotes. 

Like all members of the phenol group, creosote is a powerful 
antiseptic. The drug is eliminated in large part by the kidneys 
as guaiacol sulphate and creosol sulphate of potassium, but a 
certain proportion escapes from the body through the lungs. 

Therapeutics. — Creosote is employed chiefly as an expec- 
torant, an antiseptic, and a local anesthetic. 

Expectorant. — Creosote and its derivatives are useful ex- 
pectorants in chronic bronchitis and bronchiectasis with copious 
purulent sputum. So long ago as Addison's time creasote 
was used as a remedy for phthisis. This use was revived by 
Bouchard and Gembert in 1877, anc * again by Sommerbrodt in 
1887. While it has been shown conclusively that the drug 
has no specific influence on the tubercle bacilli in the lung, 
nevertheless the testimony of numerous observers is convinc- 
ing that it has a positive value in allaying cough, lessening ex- 
pectoration, and lowering temperature. It should be given in 
small doses gradually increased, and at once withdrawn if the 
stomach shows any intolerance. The best results are seen in 
phthisis attended with abundant sputum. Whether the drug 
has any other action than that of an expectorant and intestinal 
antiseptic is not known. 

Antiseptic. — Creosote is a valuable internal antiseptic in 
chronic gastric catarrh with flatulence and in simple dyspeptic di- 
arrhea. Creosote water has been recommended as a disinfectant 
lotion for sloughing ulcers y uterine cancer, etc., but for such a pur- 
pose it has no advantage over a dilute solution of carbolic acid. 

Local Anesthetic. — Inhalations of creosote are often use- 
ful in allaying the cough of laryngitis, bronchitis, and phthisis. 
Ten min. (0.6 c.c.) of creosote to 10 ounces (300.0 c.c.) of 
boiling - water makes a good inhalation when the catarrh is 
acute. A mixture of equal parts of creosote and spirit of 
chloroform, employed in a respirator, often serves to control 
the painful paroxysms of cough in phthisis. Doses of from 
1-2 min. (0.06-0.1 c.c.) are sometimes efficacious in the vomit- 



CREOSOTUM. 285 

ing of pregnancy, peptic ulcer, and gastric ca7icer. In toothache 
a drop or two on a pledget of cotton may be inserted in the 
cavity of the tooth. In the form of an ointment or lotion (10 
min.-i oz. — 0.6-30.0 gm.) it has been successfully employed 
to allay itching in chilblains, pruritus, and chronic eczema, but 
its odor is objectionable. 

Administration. — For internal use it is important to 
secure a preparation that is comparatively free from carbolic 
acid. The initial dose should be small (1-3 min. — 0.06-0.2 
c.c), and the amount gradually increased to 10-15 min. (0.6—1.0 
c.c). In some cases of phthisis so much as 60 or even 100 
min. (4.0-6.0 c.c.) three times daily are well borne, but such 
large doses are usually unnecessary. Creosote should be admin- 
istered after meals, and withdrawn on the first appearance of 
indigestion. Small doses may be given in capsules, but large 
doses should be given well diluted with cod-liver oil, milk, or 
a weak wine. In phthisis the drug has been administered 
hypodermically, the injections consisting of 1 part of creosote 
to 2 of olive or almond oil. This method of administration, 
however, is painful, and has little if any advantage over that 
by the mouth. Intratracheal injections have also been em- 
ployed, but guaiacol is preferable for this mode of administra- 
tion. In diarrhea creosote may be prescribed in a powder of 
bismuth, as in the following formula : 

R Creosoti, rr\xij (0.75 c.c.) ; 

Morphinse sulphatis, gr. j (0.065 gm.) ; 

Bismuthi subnitratis, ^ss (15.0 gm.). — M. 

Fiant chartulae No. xii. 
Sig. One every three hours. 

Incompatibles. — Strong nitric and sulphuric acids act 
violently upon creosote. It reduces silver salts and may ex- 
plode when triturated with* oxid of silver. It is also incom- 
patible with ferric chlorid. 

Creosote Carbonate (Creosotal). — This is an oily liquid 
containing a mixture of the carbonates of the various phenols 
found in creosote. Its chief ingredient is guaiacol carbonate. 
It is odorless, of a slightly bitter taste, insoluble in water, but 
freely so in alcohol, ether, and oils. It has pronounced advan- 
tages over creosote in having but little taste and in being more 
acceptable to the stomach. It may be employed in the same 
class of cases as creosote. Leyden and Cornet have highly 
recommended it in pulmonary tuberculosis. The dose is from 
1-3 min. (0.06-0.2 c.c), gradually increased to 10-20 min. 
(0.6-1.2 c.c), thrice daily. It may be given in capsules or in 
oil, milk, claret, or beef-tea. 



286 EXPECTORANTS. 

Guaiacol, U. S. P.— This phenol derivative is the chief 
constituent of creosote, from which it is obtained by fractional 
distillation. It is a colorless, oily liquid, having a rather un- 
pleasant aromatic odor and taste. It is slightly soluble in water, 
but freely so in alcohol and ether. It readily unites with acid 
radicles to form crystalline compounds. The dose is from 1-3 
min. (0.06-0.2 c.c), gradually increased to 20 min. (1.2 c.c). 
It should be given in the same manner as creosote. 

The action of guaiacol resembles that of carbolic acid and 
creosote. In toxic doses it causes burning in the stomach, 

The action of guaiacol resembles that of carbolic acid and 
creasote. In toxic doses it causes burning in the stomach, 
nausea and vomiting, brown-red urine, unconsciousness, and 
collapse. Wyss has reported a case of fatal poisoning in a 
girl of nine years from a dose of 80 min. (5.0 c.c). It is 
absorbed and eliminated with great rapidity, undergoing partial 
oxidation in the body, and appearing in the urine as glycur- 
onates and ether sulphates. When applied to the skin in suf- 
ficient quantity (20—30 min. — 1. 2-2.0 c.c), evaporation being 
prevented, it causes in fever a marked fall of temperature. 
This antipyretic effect follows immediately upon its absorption, 
is attended with copious perspiration and depression, and is of 
comparatively short duration. 

Guaiacol has been used internally as a substitute for creosote 
in chronic bronchitis and pulmonary tuberculosis, but it is now 
largely replaced by the more elegant carbonates of creosote 
and guaiacol. Intralaryngeal injections into the trachea of a 
mixture of guaiacol (1-2 per cent.) and olive oil are sometimes 
very useful in allaying cough in chronic pulmonary diseases. 
From 10-20 min. (0.6-1.2 c.c.) of the mixture may be injected 
once or twice a day. Guaiacol cannot be recommended as an 
antipyretic, since its external application in typhoid fever, 
tuberculosis, and other infections is sometimes followed by 
profound exhaustion and even by collapse. The drug has 
proved of some value as a local anesthetic. In epididymitis 
and orchitis the gentle inunction of an ointment of guaiacol 
and lanolin (1 : 5), followed by the application of a snugly 
fitting suspensory bandage, affords much relief. In laryngeal 
tuberculosis an oily spray of guaiacol (20-40 per cent.) is 
sometimes useful. 

Gttaiacolis Carbonas, U. S. P. — Guaiacol carbonate is 
produced by the action of carbonyl chlorid on the sodium salt 
of guaiacol. It is a white, crystalline powder, neutral in reac- 
tion, odorless and tasteless, insoluble in water, and slightly so 
in alcohol, glycerin, and oils. The dose is from 3-10 gr. (0.2- 
O.65 gm.), gradually increased to 30 gr. (2.0 gm.), thrice daily. 

According to Hesse, guaiacol carbonate is distinctly less 



PIX LIQUID A. 287 

poisonous than either guaiacol or creosote. On account of 
its freedom from odor and taste it is often much better borne 
than creosote. It is an excellant expectorant in purulent 
bronchitis, bronchiectasis, and phthisis. In doses of 10 grains 
(0.65 gm.), gradually increased to 20 grains (1.3 gm.), thrice 
daily, it has been highly recommended by Luff and others in 
rheumatoid arthritis. As it undergoes reduction in the intes- 
tine, it may be employed also as an intestinal antiseptic. It 
may be prescribed in pills, capsules, or powders. 

R Strychninae sulphatis, gr. \ (0.016 gm.) ; 

Codeinse sulphatis, gr. ij (0.13 gm.) ; 

Guaiacoli carbonatis, gr. 1 (3.0 gm.) ; 

Terebeni, TT^ 1 (3.0 c.c). — M. 

Pone in capsulas No. xxiv. 
Sig. Two capsules every four hours {subacute bronchitis). 

Potassium Guaiacol Sulphonate (Thiocol). — This 
compound occurs as a white, odorless powder, of a faintly 
bitter and then sweetish taste. It represents about 60 per 
cent, of guaiacol. Its chief advantage over the carbonate of 
guaiacol is its ready solubility in water. It may be given in 
doses of from 5-30 gr. (0.3-2.0 gm.), thrice daily, in some 
aromatic water. 

Other preparations of guaiacol are sometimes employed, 
such as the benzoate (benzosol), phosphite (guaiacol-phos- 
phal), cinnamate (styracol), and glycerol-ether (guaiamar), but 
they have no special advantages. 

PIX LIQUIDA, U. S. P. 

(Tar.) 

Tar is an empyreumatic oleoresin obtained by the destructive 
distillation of Pinus palustris and other species of Pinus. It is 
a thick, blackish liquid, having a terebinthinate odor and a 
pungent taste. It is only sparingly soluble in water, but 
freely so in alcohol, oils, and alkaline solutions. Its active con- 
stituents are guaiacols and creosols. When subjected to dis- 
tillation it yields a volatile oil — oil of tar. The dose is from 
3-15 gr. (0.2-1.0 gm.). 

Preparations. Dose. 

Oleum Picis Liquids, U. S. P 1-5 min. (0.06-0.3 c.c.). 

Syrupus Picis Liquids, U. S. P 1-4 fl. dr. (4.0-15.0 c.c). 

Unguentum Picis Liquidse, U. S. P. (50 per 

cent.). 

A water (Aqua Picis Liquidse) is also in use. It is made by shaking together 
I part of tar and 4 parts of water frequently for twenty-four hours, decanting and 
filtering. The dose is from 1-4 fl. oz. (30.0-120.0 c.c). 



288 EXPECTORANTS. 

Physiologic Action and Therapeutics. — Tar is a local 
stimulant and an antiseptic. It is chiefly employed in medicine 
as an expectorant, and as a local remedy in certain chronic 
skin diseases. In chronic bronchitis with abundant sputum 
and hard, paroxysmal cough it sometimes succeeds after other 
remedies have failed. It may be given in pills or capsules, or 
in the form of the syrup or water. Murrell has found inhala- 
tions of tar-water also useful in the same class of cases. 

In chronic eczema and psoriasis, when the lesions are sluggish, 
an ointment of tar makes a useful application ; the official oint- 
ment is generally too strong, J-2 dr. (2.0-8.0 gm.) to the ounce 
(32.0 gm.) of lard being quite sufficient in the majority of 
cases. It should always be employed tentatively, as in some 
persons the skin is exceedingly sensitive to the drug. It is 
absolutely contraindicated if the inflammation is at all active. 

OTHER STIMULANT EXPECTORANTS. 

Squill (see p. 224). — Syrup of squill, in doses of j—i fl. dr. 
(2.0-4.0 c.c.), is an excellent expectorant in the later stages of 
acute bronchitis. The compound syrup of squill contains, in 
addition to squill, senega and tartar emetic, and is too depress- 
ing for ordinary use. 

As syrup of squill contains free acetic acid, it is incompati- 
ble with ammonium carbonate and other alkaline carbonates. 

Oil of Santal (see p. ^36). — When pure, this drug often 
proves a useful expectorant in subacute and chronic bronchitis, 
with heavy, purulent sputum. Its chief drawback is its ten- 
dency to disturb the stomach. It should be given in doses of 
from 5-20 min. (0.3-1.2 c.c), in capsules or in an emulsion. 
Terebene and oil of eucalyptus are efficient synergists. 

Copaiba and Cubeb'(see pp. 234 and 235). — The oil of 
copaiba and the oleoresin of cubeb have been employed as ex- 
pectorants in chronic bronchitis with profuse purulent sputum, 
but they are neither so efficacious nor so elegant as terebene, 
oil of eucalyptus, and the preparations of guaiacol. Smoking 
cigarettes containing cubeb sometimes affords relief in the 
paroxysms of asthma. Lozenges of cubeb are useful in re- 
lieving hoarseness and fatigue of the larynx resulting from pro- 
longed use of the voice. 

Oil of Turpentine (see p. 236). — This drug, once much 
used as an expectorant in chronic bronchitis, has been largely 
replaced by terebene and terpin hydrate. Terebene (Tere- 
benum, U. S. P.) is a liquid hydrocarbon made by oxidizing 
oil of turpentine with strong sulphuric acid. The dose is 
from 5-10 min. (0.3-0.6 c.c). Terpin hydrate is a crystalline 



FERRUM. 



289 



compound obtained by the interaction of oil of turpentine, al- 
cohol, and nitric acid. The dose is from 2-15 gr. (0.1 3-1.0 
gm.). Terebene is one of the most satisfactory remedies we 
possess in bronchitis with free expectoration. In phthisis, also, 
it is of service when the catarrhal symptoms are prominent. 
In moderate doses it is usually well received, but large doses 
may excite nausea or irritation of the kidneys and bladder. 
As it is insoluble in water, it should be given in capsules, on 
sugar, in an emulsion, or in an elixir. It may also be inhaled, 
either as a spray or from the sponge of a respirator. 

Terpin hydrate has therapeutic properties similar to those 
of terebene, but it is less active. It may be given in pills, in 
capsules, or in an elixir. Terpinol, an oily body derived from 
terpin hydrate, has been employed as an expectorant in doses 
of from 3-15 min. (0.2-1.0 c.c). It is not so efficient as 
terebene. 



TONICS. 

Tonics are drugs that impart strength or tone to the 
tissues. In one sense every drug that favorably influences 
disease is a tonic, since, by removing the cause of debility, it 
serves to restore normal vitality. The term, however, is cus- 
tomarily restricted to remedies that have a more or less gen- 
eral invigorating effect, without necessarily exerting a specific 
influence on any one organ. A more exact knowledge of the 
pharmacologic action of drugs and a clearer appreciation of 
the primary causes of general weakness and malnutrition have 
tended to diminish gradually, but steadily, the number of 
remedies grouped under this heading. The following drugs 
may still be classed conveniently as tonics : 

Iron. Calcium phosphate. 

Phosphorus. Calcium hypophosphite. 

Cod-liver oil. 

Nux vomica, cinchona, and arsenic also exert a tonic influ- 
ence, but as this is subordinate to their other actions, these 
drugs have been considered in other groups. 

FERRUM, U. S. P. 

(Iron; Fe.) 

Iron is official in the form of fine, bright, non-elastic wire. 
Physiologic Action. — As iron is a constituent of the 

19 



29O TONICS. 

normal body, it may be regarded as a food as well as a medicine. 
It is especially abundant (0.4 per cent) in hemoglobin, and its 
presence in this compound is intimately associated with the 
function of the red corpuscles to carry oxygen from the lungs 
to the tissues. When iron is taken in therapeutic doses it acts 
as an astringent, causing more or less constipation. Large 
doses have an irritant effect and disturb digestion. It is now 
definitely known that both inorganic and organic preparations 
of the metal are capable of absorption. Only a small portion, 
however, of the quantity ingested enters the blood, the larger 
portion being discharged from the bowel as a sulphid and an 
albuminate, the stools, owing to the presence of the former, 
acquiring a deep black color. Absorption takes place mainly 
in the duodenum, the iron entering the general circulation 
probably as an albuminate. According to Macallum, trans- 
portation is effected through the agency of the leukocytes, 
and, more especially, of the blood-plasma. The amount that 
is absorbed varies with the nature of the preparation and the 
quantity that is administered. From the blood the iron is de- 
posited temporarily in the spleen, liver, and bone-marrow, and 
in one of these organs, perhaps the liver, it is converted into 
hemoglobin. That which is absorbed in excess of the require- 
ments of the blood is not eliminated in the secretions, but 
escapes from the body through the intestinal epithelium. Even 
when injected directly into a vein, the iron reappears chiefly in 
the intestines, and the amount of the metal in the urine is not 
materially increased. 

In health the iron naturally contained in food is all-sufficient 
for the needs of the system, and the administration of medici- 
nal iron is not followed by any notable increase in the number 
of red blood-cells or their hemoglobin value. In certain forms 
of anemia, however, especially chlorosis, chalybeate prepara- 
tions increase the amount of hemoglobin and, to a less extent, 
the number of red blood-cells. Whether the drug acts simply 
by furnishing material for the corpuscles or by stimulating the 
functional activity of the blood-making organs is not known. 

Untoward Effects. — The continued use of iron, especially 
of the ferric salts, frequently excites indigestion, constipation, 
and headache. Discoloration of the tongue and teeth also 
occasionally follows its use, and is thought to be due to the 
formation in the mouth of a black sulphid or tannate. 

Therapeutics. — The most important indication for the use 
of iron is anemia. The best effects are seen in chlorosis, in 
which disease the drug has almost a specific action. In 
secondary anemia the results of its use are less decisive, but 



FERRUM. 29I 

after the removal of the cause it serves to hasten the restora- 
tion of the blood to its normal condition. Iron plays indirectly 
the part of an emmenagogue in amenorrhea dependent upon 
anemia. Some of its salts are used as astringents and styptics. 

Contraindications. — The chief contraindication is gastric 
irritation. It is generally badly borne, probably on account 
of impaired digestion, in febrile diseases and in gout. 

Administration. — Ordinarily iron should be administered 
by the mouth and after meals. The least astringent prepara- 
tions are the carbonate, citrate, ammonioferric citrate, am- 
monioferric tartrate, pyrophosphate, and reduced iron. The 
numerous organic compounds of iron with albumin have no 
great advantages over many of the older inorganic salts, but 
they are less liable to disturb digestion, and are, probably, 
somewhat more readily absorbed. In exceptional cases iron 
may be given hypodermically. For this purpose a freely 
soluble preparation, such as ammonioferric citrate, should be 
selected, and the solution should be freshly prepared and well 
diluted. 

Incompatibles. — Ferrous and ferric salts are incompatible 
with all preparations containing tannic or gallic acid ; with 
ammonia, alkaline carbonates, and mucilage of acacia. 

FERRUM REDUCTUM, U. S. P. 

(Reduced Iron; Iron by Hydrogen; Quevenne's Iron.) 

Reduced iron is a fine, grayish-black, insoluble powder, 
without odor or taste. When pure it is quite free from irritat- 
ing properties, and, being but feebly astringent, it has little 
tendency to cause constipation. It is employed only as a 
hematinic. It maybe given in doses of from 1-5 gr. (0.06-0.3 
gm.), in pills, capsules, or lozenges. 

FERRI CARBONAS. 

(Iron Carbonate; Green Ferrous Carbonate; FeC0 3 .) 

Iron carbonate is an unstable compound which is readily 
converted into ferric hydrate on exposure to air. It is not 
official. 

Preparations. Dose. 

Ferri Carbonas Saccharatus, U. S. P. (con- 
tains 15 per cent, of freshly precipitated 
ferrous carbonate, protected from oxida- 
tion by sugar) 5-15 gr. (0.3-1.0 gm.). 

Mistura Ferri Composita, U. S. P. (com- 
pound iron mixture; Griffith's Mixture: 
carbonate of iron in suspension with 
potassium sulphate, myrrh, and sugar) . 1-4 fl. dr. (4.0-15.0 c.c). 



292 TONICS. 

Preparation. Dose. 

Massa Ferri Carbonatis, U. S. P. (Vallet's 
Mass : about 42 per cent, of ferrous car- 
bonate with sugar and honey) 3-5 gr. (0.2-0.3 S 111 -)- 

Pilulas Ferri Carbonatis, U. S. P. (Blaud's 
Pills: each pill contains about I gr. — 
0.06 gm. — of ferrous carbonate, made 
with crystallized ferrous sulphate and 
potassium carbonate) ........ 1-3 pills. 

Therapeutics. — These preparations are comparatively free 
from astringency, and are convenient forms in which to admin- 
ister iron. They are used solely in anemia. The saccharated 
carbonate and the pills of the carbonate (Blaud's pills) are the 
favorite preparations. The former should be given also in 
pills or else in capsules. Griffith's mixture is superfluous. 
Some practitioners prefer Blaud's pills made according to the 
original formula (equal parts of potassium carbonate and dried 
ferrous sulphate) to those made according to the official 
formula. The former contain a certain amount of free potas- 
sium carbonate. 

FERRI CHLORIDUM, U. S. P. 

(Ferric Chlorid; Sesquichlorid or Perchlorid of Iron; Fe 2 Cl 6 -4- 12 H 2 0.) 

Ferric chlorid occurs in deliquescent, orange-yellow crystal- 
line pieces, having an astringent, chalybeate taste. It is not 
used internally, but sometimes externally as an astringent or a 
styptic. 

Preparations. Dose. 

Liquor Ferri Chloridi, U. S. P. (contains 
about 29 per cent, of the crystallized 

salt) 3-10 min. (0.2-0.6 c.c). 

Tinctura Ferri Chloridi, U. S. P. (contains 
about 13 per cent, of anhydrous ferric 
chlorid, with alcohol, water, and a trace 

of nitrous ether) 5-30 min. (0.3-2.0 c.c). 

Liquor Ferri et Ammonii Acetatis, U. S. P. 
(Basham's Mixture: Tincture of ferric 
chlorid, 4 parts; dilute acetic acid, 6 
parts; solution of ammonium acetate, 5° 
parts; aromatic elixir, 12 parts; glycerin, 
12 parts; water, to make 100 parts) . . 1-4 fl. dr. (4.0-15.0 c.c). 

Therapeutics. — The solution of ferric chlorid may be 
used locally as a styptic in controlling bleeding after the ex- 
traction of teeth, removal of tonsils, or application of leeches. 
In postpartum hemorrhage it should not be used except as a 
last resort. It may occasionally be of service in hematemesis 
and entrorrhagia, on account of its local action, but it cannot 
possibly do good in other internal hemorrhages. 



FERRUM. 



293 



External pedunculated piles have been successfully treated 
by injecting them, after they have been clamped, with a few 
minims of the tincture. The treatment of aneurysm by injec- 
tions of ferric chlorid, as first advised by Pravaz, is dangerous, 
and fortunately obsolete. The tincture, in the strength of \-\ 
fl. dr. (2.0-4.O c.c.) to the ounce (30.0 c.c.) of water, may be used 
as an astringent application in chronic pharyngitis and laryngitis. 
Ferric chlorid in the form of the tincture or the solution is a 
valuable local remedy in pharyngeal diphtheria. It may be 
prescribed as follows : 

R Tincturae ferri chloridi, fgj-iij (4.0-1 1.0 c.c); 

Glycerini, f^ss (15.0 c.c); 

Aquae, q. s. ad f^j (30.0 c.c). — M. 

Or as Loffler's solution : 

R Menthol, giiss ( 10.0 gm.) ; 

Toluol, fgx (36.0 c.c.) ; 

Alcoholis absoluti, f^ij (60.0 c.c.) ; 

Liquoris ferri chloridi, fgj (4.0 c.c). — M. 

The tincture is an efficient hematinic in anemia, but it is 
more liable than many of the other preparations of iron to 
injure the teeth, disturb digestion, and induce constipation. 
Basham's mixture is a favorite chalybeate diuretic in chronic 
nephritis ; only small doses, however, should be given, and 
even these should be withheld if the drug causes constipation 
and headache. The tincture has long been regarded as a spe- 
cific in erysipelas. This claim cannot be substantiated, although 
the drug is of benefit in some cases. It may be given in doses 
of from 15-20 min. (i. 0-1.2 c.c.) every two or three hours. 

Administration. — The tincture of ferric chlorid should be 
taken after meals, well diluted, through a tube. 

Ferrum Dialysatum {Dialyzed Iron). — This is an un- 
official preparation of the oxychlorid of iron from which acidul- 
ous matter has been removed by dialysis. It is a dark-red, 
tasteless, neutral liquid, quite free from astringency. It is a very 
unstable compound, and undergoes rapid decomposition in the 
stomach. It is an extremely feeble chalybeate, but a useful 
antidote in arsenical poisoning. 

The dose as a hematinic is from 10-30 min. (0.6-2.0 c.c.) ; as 
an antidote, | fl. oz. (15.0 c.c.) frequently repeated. 

FERRI HYDROXIDUM, U. S. P., AND FERRI HYDROXIDUM 
CUM MAGNESII OXIDO, U. S. P. 

(Ferric Hydroxid; Fe (OH) 3 and Ferric Hydroxid with Magnesia.) 

These preparations are used exclusively as antidotes in ar- 
senical poisoning. The former may be precipitated from any 



294 TONICS. 

liquid preparation of iron by adding to it an alkali (ammonia 
or sodium carbonate) ; the latter, by adding magnesia in excess. 
If a caustic alkali has been employed, such as ammonia, the 
excess should be removed by transferring the precipitate to a 
muslin filter, squeezing it and washing it with fresh water. 
Ferric hydroxid with magnesia is preferable, since it needs no 
washing, and since the magnesia itself is antidotal. These 
preparations should be freshly made and given freely, while still 
moist, in doses of a tablespoonful or more every few minutes. 

FERRI SULPHAS, U. S. P. 

(Ferrous Sulphate; Green Vitriol; FeS0 4 -f 7H 2 0.) 

Ferrous sulphate occurs as pale, bluish-green, efflorescent 
prisms, having a saline, styptic taste. The dose is from 1-5 
gr. (0.06-0.3 gm.). 

Preparations. Dose. 

Ferri Sulphas Exsiccatus, U. S. P 1-3 gr. (0.06-0.2 gm.). 

Ferri Sulphas Granulatus, U. S. P. ... 1-5 gr. (0.06-0.3 g m -)- 

Mistura Ferri Composita (Griffith's Mix- 
ture) 1-4 rl. dr. (4.0-15.0 c.c). 

Pilulae Aloes et Ferri (contain about 1 gr. 

— 0.06 gm. — of each) 1-3 pills. 

Pilulse Ferri Carbonatis (Blaud's Pills) . . 1-3 pills. 

Therapeutics. — Sulphate of iron is an active astringent. 
It may be employed as a hematinic in anemia attended by re- 
laxation of the bowels. The dried sulphate should be selected 
for pills. 

Crude ferrous sulphate, or copperas, is used as a disinfect- 
ant and deodorizer for privies, cess-pools, etc., but its germi- 
cidal power is very feeble. 

FERRI SUBSULPHAS. 

(Ferric Subsulphate; Basic Ferric Sulphate ; Monsel's Salt ; Fe 4 0(S0 4 ) 5 .) 

Ferric subsulphate is a yellow, hygroscopic, astringent 
powder, freely soluble in water. 

Preparation. Dose. 
Liquor Ferri Subsulphatis, U. S. P. (Mon- 
sel's Solution) 3-5 min. (0.2-0.3 c.c). 

Therapeutics. — Monsel's solution is a prompt and power- 
ful styptic, which is somewhat less irritant in its action than 
the solution of ferric chlorid. It is employed chiefly as a 
local hemostatic. When used too freely it produces hard black 
clots, which may serve to conceal deep-seated hemorrhage. 
For this reason it should not be poured into the wound, but 



FERRUM. 295 

applied directly to the bleeding surface on a pledget of cotton. 
In hematemesis a few drops in water may prove efficient. It 
has been recommended in the form of a spray in hemoptysis, 
but it is of doubtful utility. 



FERRI ET AMMONII SULPHAS, U. S. P. 

(Ferric Ammonium Sulphate; Ammonioferric Alum.) 

Ammonioferric alum occurs as pale-violet, efflorescent crys- 
tals, odorless, and of a sour, styptic taste. It is a more 
powerful astringent than ordinary alum (aluminum and 
potassium sulphate). It has been employed in saturated solu- 
tion as a hemostatic in capillary bleeding, and in weak solutions 
as an astringent injection in leukorrhea. 

FERRI IODIDUM. 

(Ferrous Iodid ; Protiodid of Iron; Fel 2 .) 

Ferrous iodid occurs in grayish-white, crystalline masses 
which are soluble in water with partial decomposition. It is 
rarely used in the pure form. 

Preparations. Dose. 

Syrupus Ferri Iodidi, U. S. P. (contains 5 

per cent, by weight of ferrous iodid) . . 5-60 min. (0.3-4.0 c.c). 
Pilulae Ferri Iodidi, U. S. P. (contain 

about I gr. — 0.06 gm. — of ferrous 

iodid) 1-3 pills. 

Therapeutics. — Iodid of iron may be employed when it 
is desirable to combine an alterative with a chalybeate. It is 
a very useful preparation in tuberculous adenitis, syphilitic 
cachexia, and rachitis. It is usually well tolerated by children, 
to whom the syrup may be given in doses of from 3-20 
min. (0.2-1.2 c.c), thrice daily, after meals. J. C. Wilson has 
found large doses of the syrup efficacious in articidar rheuma- 
tism and other forms of acute arthritis after failure with salicylic 
compounds. 

As the syrup is injurious to the teeth, it should be taken 
well diluted, and the mouth should be thoroughly rinsed after 
its administration. 

FERRI CITRAS, FERRI PHOSPHAS, AND FERRI TARTRAS. 

These compounds are known as the scale preparations, be- 
cause concentrated solutions of them are spread on plates of 
glass and allowed to evaporate, so that the salts may be 
obtained in the form of scales. The following are official: 



296 TONICS. 

Preparations. Dose. 

Ferri Citras, U. S. P 2-5 gr. (0.13-0.3 gm.). 

Ferri et Ammonii Citras, U. S. P. (contains 

16 per cent, of metallic iron) 5-10 gr. (0.3-0.6 gm.). 

Ferri et Quininse Citras, U. S. P. (contains 

1 1.5 per cent, of quinin and 13.5 per 

cent, of metallic iron) 5-IO gr. (0.3-0.6 gm.). 

Ferri et Quininae Citratis Solubilis, U. S. P. 

(same strength as preceding preparation, 

but more soluble) .... 5~io gr. (0.3-0.6 gm.). 

Ferri et Strychninse Citras, U. S. P. (con- 
tains 1 per cent, of strychnin and 16 

per cent, of metallic iron) 1-5 gr. (0.065-0.3 gm.). 

Ferri et Ammonii Tartras, U. S. P. (con- 
tains 13 per cent, of metallic iron) . . 5-10 gr. (0.3-0.6 gm.). 
Ferri et Potassii Tartras, U. S. P. (contains 

15 per cent, of metallic iron) 5~io gr. (0.3-0.6 gm.). 

Ferri Phosphas Solubilis, U. S. P. (the 

solubility of this salt is dependent upon 

the presence of free sodium citrate) . . 3-10 gr. (0.2-0.6 gm.). 
Ferri Pyrophosphas Solubilis, U. S. P. (the 

solubility of this salt is dependent upon 

the presence of free sodium citrate) . . 3-10 gr. (0.2-0.6 gm.). 

From iron and quinin citrate, bitter wine of iron {Vinum 
Ferri Amarum, U. S. P.) is prepared, and from iron and ammo- 
nium acetate wine of iron ( Vinum Fetri, U. S. P.) is prepared. 
The dose of either wine is from 1-3 fl. dr. (4.0-1 1. o c.c). Iron 
phosphate enters into the glycerite of the phosphates of iron, 
quinin, and strychnin {Glyceritum Ferri, Quininee et Strychnines 
Phosphatum), the dose of which is 10-30 min. (0.6-2.0 c.c), 
and the syrup of the phosphates of iron, quinin, and strychnin 
(Syrupus Ferri, Quinines et Strychnince Phosphatum, U. S. P.), 
the dose of which is from 1-2 fl. dr. (4.0-8.0 c.c). 

Therapeutics. — The scale preparations of iron are mild 
and agreeable hematinics. They are comparatively free from 
astringency, and are usually well borne by the stomach. On 
account of their solubility they are well adapted for administra- 
tion in liquid form. 

FERRUM ALBUMINATUM. 

Bunge first demonstrated that iron exists in the tissues and 
in various food-stuffs in the form of a nucleo-albuminate. He 
subsequently succeeded in separating such a compound from 
the yolk of eggs, and this he called hematogen. The latter 
differs from ordinary iron salts in being very resistant to the 
action of sulphids. According to Bunge, inorganic prepara- 
tions of iron are not absorbed to any extent by the healthy 



FERRUM. 297 

mucous membrane of the alimentary canal, and are useful in 
anemia only by disposing of the sulphureted hydrogen in the 
intestine, and thus protecting the food-iron from reduction 
until its absorption has been accomplished. Recent investiga- 
tions have proved conclusively that Bunge's view is fallacious, 
and that inorganic iron compounds are quite capable of absorp- 
tion and assimilation. Albuminates and peptonates of iron, 
however, are often better borne by the stomach than the in- 
organic salts, are less injurious to the teeth, and are, perhaps, 
somewhat more readily absorbed. Many attempts have been 
made to produce artificially, and in a way that can be prac- 
tically utilized, compounds having the characteristics of 
Bunge's hematogen. Schmiedeberg obtained from pig's liver 
a compound containing from 6-8 per cent, of iron, which he 
called ferratin. Later this preparation was obtained in larger 
quantities by the action of iron salts on egg-albumen. It is a 
fine, reddish powder, without odor or taste, insoluble in water, 
but soluble in dilute alkalis. The dose is from 3-10 gr. (0.2- 
0.6 gm.). It may be given in capsules, powders, or tablets, or 
with milk. Kobert has obtained two compounds — hemogallol 
and hemol — from ox-blood by reducing the hemoglobin with 
pyrogallol and zinc dust respectively. The dose of either 
compound is from 2-8 gr. (0.13-0.5 gm.). 

Ferri l/actas {Ferrous Lactate). — This preparation occurs 
in pale, greenish-white, crystalline crusts, having a slight 
characteristic odor and a sweetish, ferruginous taste. It is 
slowly soluble in water. It may be given in doses of from 1-5 
gr. (0.06-0.3 gm.). 

Ferri Oxalas (Ferrous Oxalate). — This salt occurs as a 
pale-yellow, odorless, crystalline powder, insoluble in water. 
It has been lauded by Quincke and by Hayem as a hematinic in 
chlorosis, but it does not seem to have any special advantages. 
The dose is from 3-5 gr. (0.2-0.3 gm.). 

Ferri Hypophosphis, U. S. P. (Ferric Hypophosphite). 
— This salt occurs as a white, odorless, and almost tasteless 
powder, slightly soluble in water. It has no special advan- 
tages. The dose is from 5-10 gr. (0.3-0.6 gm.). It is con- 
tained in the compound syrup of hypophosphites {Syrupus 
Hypophosphitum Compositus, U. S. P.), the dose of which is 
from 1-4 fl. dr. (4.0-15.0 c.c). 

Ferri Valeras {Ferric Valerate). — This compound is a 
dark-red, amorphous powder, having the odor of valerian and 
a mild styptic taste. It may be given with other valerates when 
a combined chalybeate and anti-spasmodic action is desired. 
The dose is from 1-3 gr. (0.06-0.2 gm.). 



298 TONICS. 

PHOSPHORUS, U. S. P. 

Phosphorus is a yellowish, semitransparent, non-metallic 
element obtained from bones. It has a waxy consistence and 
luster, a peculiar, garlicky odor, and a disagreeable taste. By 
long keeping it turns red, and occasionally black. On ex- 
posure it emits white fumes, which are luminous in the dark, 
and on longer exposure it takes fire spontaneously. It is al- 
most insoluble in water, soluble in 350 parts of absolute 
alcohol and in 50 parts of fatty oils, and readily soluble in 
chloroform. The dose is from 1 ] Q ^ gr. (0.00064-0.002 gm.). 

Preparation. Dose. 
Pilulse Phosphori, U. S. P. (each pill con- 
tains ywg g 1 "- — 0.0006 gm.) 1-3 pills. 

Physiologic Action. — Wegner found that when phos- 
phorus was given in small doses to growing animals it rendered 
the bones more dense, diminished the cancellous structure, 
and finally caused more or less obliteration of the marrow- 
cavity. That these changes were due to the stimulation of the 
bone-forming tissues, and not to the deposition of an excess 
of phosphates, was shown by the fact that in animals fed with 
phosphorus but deprived of phosphates the same hyperplasia 
in the bones resulted, but that the new tissue was soft and 
gelatinous instead of hard. Apart from these changes in the 
osseous system, and perhaps a slight increase in the number 
of red blood-cells, the effects of phosphorus in medicinal 
doses are not very obvious. There is considerable clinical 
testimony, however, to show that the drug improves the nutri- 
tion of other tissues, especially of the nervous system. 

The manner in which phosphorus is absorbed has been a 
matter of some dispute ; it probably enters the blood chiefly 
as phosphorus, absorption being facilitated by the solution of 
the drug in the fatty substances present in the bowel. A small 
part is volatilized in the alimentary canal, and probably enters 
the tissue in the form of vapor. Phosphorus is eliminated 
in minute quantities as phosphorus by the lungs and partly 
by the kidneys as proteid compounds, and, probably, as 
phosphates. 

Toxicology. — Toxic doses of phosphorus do not usually 
produce their effects for several hours. The earliest symptoms 
are intense abdominal pain, obstinate vomiting, thirst, a gar- 
licky taste in the mouth, restlessness, and prostration. The 
ejected material contains mucus, bile, and occasionally disinte- 
grated blood, and is luminous in the dark. At the end of 
from twenty-four to thirty-six hours the symptoms gradually 



PHOSPHORUS. 299- 

subside and the patient feels comparatively comfortable, but 
soon the vomiting and pain return, jaundice develops, the liver 
becomes enlarged and painful, the pulse grows very feeble, 
and not infrequently ecchymoses appear in the skin and 
hemorrhages occur from the mucous membranes. The urine 
is scanty and contains albumin, tube-casts, bile, sarcolactic 
acid, an increased amount of ammonia, and sometimes leucin, 
tyrosin, and sugar. In fatal cases death occurs generally in 
from a few days to two weeks, and is often preceded by deli- 
rium, convulsions, stupor, and coma. Occasionally, phosphorus 
kills within a few hours, probably through its direct depressant 
influence on the heart. If the patient recovers, the symptoms 
abate very slowly and the convalescence is tedious. 

The changes in the organs observed after death are attri- 
butable to grave disturbances of tissue-metabolism and not to 
the direct irritant action of the drug. The most characteristic 
feature is wide-spread fatty degeneration of the tissues. The 
latter is especially marked in the glands of the stomach and 
intestines, in the liver, kidneys, heart, and muscles. Ecchy- 
moses are found in most of the organs. Areas of complete 
necrosis are often observed in the stomach and liver. In sub- 
acute poisoning the degenerated parenchyma may be replaced 
in part by newly formed connective tissue. Whether the fat 
found in the cells of the various organs is formed in situ or is 
carried to them from the subcutaneous tissues is a moot 
question. 

Treatment. — If the phosphorus has been recently taken, 
the stomach should be washed out at once. Copper sulphate 
is probably the best emetic, since any excess may serve as an 
antidote by forming with the phosphorus insoluble phosphid 
of copper. A cathartic should be given to remove from the 
bowel any of the poison that may still be unabsorbed. All 
oily and fatty matters should be withheld, since they are 
active solvents of phosphorus. Various oxidizing agents have 
been employed as chemical antidotes. Potassium permangan- 
ate (J per cent, aqueous solution) and the solution of peroxid 
of hydrogen are the most useful. Old French oil of turpen- 
tine, which is rich in ozone, has been repeatedly recommended, 
but it cannot be obtained in this country, and ordinary tur- 
pentine is useless. 

Chronic Phosphorus-poisoning. — Workmen employed in 
match factories and who are exposed to the fumes of phos- 
phorus develop a symptom-complex to which Magitot has 
applied the name phosphorism. This condition is char- 
acterized by anemia, loss of flesh, a garlicky odor of the 



300 TONICS. 

breath, chronic diarrhea, albuminuria, fragility of the bones, 
and, in many instances, by necrosis of the maxillary bone. 
Since phosphorus necrosis occurs only in workmen who have 
carious teeth, it is usually attributed solely to the local ac- 
tion of the fumes, but there are good reasons for believing 
that systemic infection contributes largely to its development. 
Thus it rarely appears, despite the existence of carious teeth, 
until the worker has been some time, generally many years, at 
his trade ; the sufferer nearly always manifests some of the 
symptoms of systemic saturation, and finally, Stubenrauch has 
demonstrated experimentally, that phosphorous fumes exert 
no especial action on exposed bone or periosteum. 

Red or amorphous phosphorus being insoluble in ordinary 
liquids and non-volatile is free from toxic properties. Phos- 
phoric acid has none of the qualities of phosphorus, and acts 
merely as a mild stomachic. Sodium phosphate is an agree- 
able laxative. The hypophosphites of calcium, sodium, and 
potassium are innoxious, and are employed as tonics. Sodium 
phosphite is extremely poisonous. Sodium pyrophosphate and 
sodium metaphosphate, when administered hypodermically, 
paralyze the central nervous system and the heart, and in 
slow poisoning produce fatty degeneration of the glandular 
organs and numerous hemorrhagic extravasations. 

Therapeutics. — Phosphorus is employed as a tonic in cer- 
tain diseases of the nervous system that are dependent upon 
exhaustion rather than upon organic changes. Thus, it is 
sometimes of service in neurasthenia, neuralgia, and impotence 
from sexual excesses. It has been employed in rachitis, 
according to Monti, since 1838, but its reputation in this 
disease is due largely to the very favorable reports of Kas- 
sowitz, in Europe, and of Jacobi, in this country. It is not 
unlikely that much of the benefit which has been observed in 
rachitic subjects while taking phosphorus has been due in 
reality to the cod-liver oil, simultaneously administered, and to 
the improvement in the diet and general hygiene. This view 
receives some support from the recent investigations of Zweifel, 
who found that phosphorus in cod-liver oil was soon con- 
verted, through oxidation, into phosphoric acid, and, therefore, 
lost its peculiar properties. Monti contends that phosphorus 
alone has not staid the progress of rachitis nor has it caused 
the slightest improvement. 

Phosphorus has also been employed with asserted good 
results in other diseases of bones, such as osteomalacia, caries, 
and delayed union of fractures. 

Administration. — As phosphorus undergoes oxidation on 



C A LCI I PHOSPHAS. 3OI 

keeping in nearly all menstrua, only freshly made preparations 
should be prescribed. It may be administered conveniently 
in the form of an elixir. 

R Phosphori gr. ss (0.032 gm.) ; 

Alcoholis absoluti f^iij (11.0 c.c) ; 

Olei anisi Tttiij (0.18 c.c); 

Glycerini f^iss (45.0 c.c); 

Elixiris aromatici q. s. ad f|iij (90.0 c.c). — M. 

Sig. Thirty min. (1.8 c.c.) equal about j^ gr. (0.0006 gm.) of phosphorus. 

Persons vary considerably in their susceptibility to phos- 
phorus, and, therefore, the initial doses should be small, espe- 
cially in children. Nebelthau has cited an instance in which 
death occurred in a well-developed child of two years after 
taking less than •£§ gr. (0.003 S m -) m tne course of sixty 
hours. Even minute doses sometimes disturb the stomach 
and excite unpleasant eructations. 

ZiTid Phosphidum (Zinc Phosphid). — This compound 
appears as a dark-gray, gritty powder, or as crystalline, me- 
tallic fragments having a faint odor and taste of phosphorus. 
It is insoluble in alcohol or water. The dose is from 3 ~ i gr. 
(0.002-0.006 gm.), in pill. Its action closely resembles that 
of phosphorus, and it may be used for the same purposes as 
the latter. 

Acidum Phosphorieum, U. S. P. (Phosphoric Acid). — 
This is a colorless liquid, composed of 85 per cent, by weight 
of absolute orthophosphoric acid and 1 5 per cent, of water. It 
has a strongly acid taste. The dose is from 3-5 min. (0.2-0.3 
c.c), well diluted. Its action is somewhat like that of the 
dilute mineral acids, and bears no resemblance to that of phos- 
phorus. It may be employed to allay thirst in diabetes and 
febrile diseases. It has also been used to promote gastric 
digestio?i, but for this purpose it is inferior to hydrochloric 
acid. It is usually prescribed as diluted phosphoric acid 
(Acidum Phosphoricum Dilutum, U. S. P.), the dose of which is 
from 10-60 min. (0.6-4.0 c.c), in water. 

CALCII PHOSPHAS. 

(Calcium Orthophosphate ; CagfPO^.) 

Calcium phosphate is official as Calcii Phosphas Prcecipitatus , 
a white, odorless, tasteless, amorphous powder, almost insolu- 
ble in water. The dose is from 5-30 gr. (0.3-2.0 gm.). 

Preparation. Dose. 

Syrupus Calcii Lactophosphatis, U. S. P. 
(contains about 3 per cent, of the double 
soluble salt) 1-4 fl. dr. (4.0-15.0 c.c). 



302 TONICS. 

Physiologic Action and Therapeutics. — The insoluble 
salts of calcium, of which the phosphate may be taken as a 
type, have no very pronounced effects upon the system. When 
taken internally, the greater part resists absorption and reap- 
pears in the stools ; a small portion, however, enters the cir- 
culation, and in case of any deficiency in the lime-salts of the 
food is appropriated by the tissues. In the absence of a 
deficiency in the natural supply, any excess of lime, if it does 
not fail altogether of absorption, is slowly excreted by the 
intestinal epithelium and kidneys. As food ordinarily contains 
more lime than the body requires, it is difficult to understand 
how the phosphate or hypophosphite of calcium can be of 
service when administered as a remedy. The difficulty, how- 
ever, is no greater than that which is encountered in attempt- 
ing to explain the undoubted efficacy of iron in chlorosis, a 
disease that is certainly not dependent upon a want of iron- 
salts in the food. 

Calcium phosphate has been recommended, on theoretic 
grounds, in rachitis and osteomalacia, but it is of very doubt- 
ful value. The testimony to its favorable influence on general 
nutrition in such diseases as tuberculosis, tertiary syphilis, and 
neurasthenia is more convincing, but even here it is not 
unlikely that much of the good attributed to the phosphate is 
in reality due to the remedies usually associated with it. 

Administration. — Calcium phosphate may be prescribed 
in powders or capsules. The lactophosphate, being soluble, 
may be given in the form of the official syrup or in an emul- 
sion of cod-liver oil. 

Calcii Glycerophosphas. — The fact that phosphorus 
exists in the nervous system in the form of glycerophosphoric 
acid has led to the introduction of the salts of this acid as 
substitutes for phosphates and hypophosphites. They have 
been used chiefly in exhaustion from overwork, in tardy con- 
valescence from the specific fevers, in neurasthenia, phosphaturia, 
and exophthalmic goiter. The dose of calcium glycerophosphate 
is from 2-5 gr. (0.1-0.3 g m -)> m solution or gelatin-coated 
pills. Sodium glycerophosphate is employed in the same 
dose, and may be given by the mouth or hypodermically. 

CALCII HYPOPHOSPHIS, U. S. P. 

(Calcium Hypophosphite; Ca (PH 2 2 ) 2 .) 

Calcium hypophosphite occurs in colorless, transparent 
crystals, or small, lustrous scales, of a nauseous, bitter taste. 
It is soluble in about 7 parts of water. The dose is from 5-30 
gr. (0.3-2.0 gm.). 



b 



OLEUM MORRHU^. 303 

Preparations. Dose. 

Syrupus Hypophosphitum, U. S. P. (cal- 
cium hypophosphite, 4.5 per cent. ; 

sodium hypophosphite, 1.5 per cent.; 

potassium hypophosphite, 1. 5 per cent. ; 

dilute hypophosphorous acid, 0.2 per 

cent.; spirit of lemon, sugar, and water), 1-2 fl. dr. (4.0-8.0 c.c.). 
Syrupus Hypophosphitum Compositus, U. 

S. P. (calcium hypophosphite, 3.5 per 

cent.; potassium hypophosphite, 1.7 per 

cent. ; sodium hypophosphite, 1.7 per 

cent. ; ferric hypophosphite, 0.2 per cent. ; 

manganese hypophosphite, 0.2 per cent. ; 

quinin, 0.1 per cent. ; strychnin, 0.0 1 per 

cent. ; sodium citrate, 0.37 per cent. ; 

dilute hypophosphorous acid, 1.5 per 

cent. ; sugar and water) 1-2 fl. dr. (4.O-8.O c.c). 

Emulsum Olei Morrhuae cum Hypophos- 

phitibus, U. S. P 1-8 fl. dr. (4.0-30.0 c.c). 

Therapeutics. — Hypophosphites may be employed in the 
same class of cases as that in which calcium phosphate has 
been recommended. 

OLEUM MORRHUiE, U. S. P. 

(Cod-liver Oil.) 

Cod-liver oil is a fixed oil obtained from the livers of Gadus 
morrhua and other species of Gadus. The shore oil, or white 
oil, the only variety at present used for medicinal purposes, is 
extracted by disintegrating the fresh livers with superheated 
steam, and subsequently straining the resultant pultaceous 
mass. It is a pale yellow, thin liquid, having a peculiar fishy 
odor and taste. In addition to olein, palmitin, stearin, and 
other fatty principles it contains traces of iodin, bromin, phos- 
phorus, cholesterin, trimethylamin, and, possibly, of bile-salts. 
The dose is from 1-4 fl. dr. (4.0-15.0 c.c). 

Preparations. Dose. 

Emulsum Olei Morrhuge, U. S. P. (50 per 

cent.) 1-8 fl. dr. (4.0-30.0 c.c). 

Emulsum Olei Morrhua? cum Hypophos- 
phitibus, U. S. P. (cod-liver oil, 50 per 
cent. ; calcium hypophosphite, I per 
cent. ; potassium hypophosphite, 0.5 per 
cent. ; sodium hypophosphite, 0.5 per 
cent. ; oil of gaultheria, syrup, and water) 1-8 fl. dr. (4.0-30.0 c.c). 

Physiologic Action and Therapeutics. — Cod-liver oil 
is a food rather than a medicine. It is superior to other fats, 
because it is more digestible and assimilable. The amount of 
iodin and of phosphorus present is too small for these ingredi- 
ents to exert any specific action. Attempts to isolate an active 



304 TONICS. 

principle have not been attended with success. The ready- 
absorption of cod-liver oil has been attributed by some 
authorities to the presence of biliary salts ; by others, to the 
presence of free fatty acids, but no explanation that has yet 
been offered is perfectly satisfactory. In moderate doses cod- 
liver oil improves the general nutrition, increases the number 
of red blood-cells, and favors the accumulation of fat in the 
body. Large doses excite nausea, eructations, vomiting, and 
diarrhea. 

Cod-liver oil, provided it is well borne by the stomach, may 
be employed in any disease in which malnutrition is a promi- 
nent feature ; thus it is often of great service in tuberculosis 
of the lungs, bones, or lymph-glands, in rickets, tertiary syphilis, 
chronic rheumatism, rheumatoid arthritis, chronic bronchitis, con- 
valescence from the specific fevers, and secondary anemia. In 
the early stage of phthisis it does more good than any other 
medicinal agent, but it must be given cautiously and with- 
drawn upon the first evidence of intolerance. When symptoms 
of secondary infection are prominent, such as fever, sweating, 
and rapid wasting, it is less likely to be well borne or to do 
good. In conjunction with general hygienic measures, the 
prolonged use of cod-liver oil is also valuable in preventing 
the development of tuberculosis in those who, through phy- 
sique and heredity, have a marked predisposition to the disease. 

Contraindications. — High fever and gastric or intestinal 
irritation are the chief contraindications to its use. 

Administration. — Patients who at first have difficulty in 
taking cod-liver oil may ultimately acquire a tolerance for it 
if the dose be carefully adapted to their digestive powers. It 
is well, therefore, to begin with very small doses, even a few 
minims, and to increase the amount gradually as the stomach 
becomes accustomed to it. A single dose at bedtime may be 
well borne when the stomach will not tolerate it during the 
day. As the oil is digested in the intestine, and not in the 
stomach, its stay in the latter should be reduced to a minimum, 
and this can be accomplished by administering it two or three 
hours after meals. Although it is impossible to disguise com- 
pletely the fishy odor and taste of cod-liver oil, there are many 
ways in which the unpleasantness of its administration may be 
lessened. It may be floated on the surface of whisky or 
porter, care being taken to prevent it from touching the glass, 
and swallowed quickly; it may be taken in ketchup or in 
tincture of orange peel, but perhaps the best way to prescribe 
it is in soft capsules holding from 10-60 min. (0.6—4.0 c.c). 
or in a well-made emulsion. Emulsions containing 50 per 



AL TERA TIVES. 305 

cent, of oil may be made with yolk of egg, acacia, or malt 
extract, and flavored with oil of bitter almond, gaultheria, or 
cinnamon. 

R Olei morrhuae, f^iv (118.0 c.c); 

Olei amygdalae amarae, n\, x (0.6 c.c); 

Acaciae, q. s. 

Syrupi calcii lactophosphatis, fi§ij (60.0 c.c.) ; 

Aquae, q. s. ad f^viij (235.0 c.c). — M. 

Sig. A tablespoonful twice daily, two hours after meals. 

The official emulsions are made with acacia and are flavored 
with oil of gaultheria. 

As a rule, children take cod-liver oil readily, and even grow 
to like it; but if it cannot be taken by the mouth, owing to 
gastric irritability, it may be given by inunction. Just before 
retiring, and after a warm bath, 1 or 2 drams (4.0-8.0 c.c.) of 
the oil should be rubbed into the skin over the chest and 
abdomen, and the child put to bed in a flannel night-dress. 



ALTERATIVES. 

Alteratives are agents that favorably modify general morbid 
processes without exerting a demonstrable influence on any 
particular organ. It need scarcely be said that the manner 
of their action is quite unknown; if it were known, these 
remedies could be better apportioned among other classes. 
The term alterative is simply applied for convenience to a 
group of heterogeneous drugs that experience has shown to 
be more or less efficacious in certain constitutional diseases, 
the real nature of which is very imperfectly understood. The 
most important members of this group are : 

Arsenic. Guaiac. 

Iodids. Sarsaparilla. 

Iodin. Jambul. 

Iodoform. Mezereum. 

Mercury. Calx sulphurata. 

Ichthyol. Uranium nitrate. 

Gold and sodium Gland extracts (thyroid, thymus, 

chlorid. and testicular extracts). 

Colchicum. 

ARSENUM. 

(Arsenic ; As.) 

Arsenic is not employed for medicinal purposes in the 
metallic form, but as arsenic trioxid, as a salt of arsenous acid 
(an arsenite), or as a salt of arsenic acid (an arsenate). 
20 



306 AL TERA TIVES. 

Preparations. Dose. 

Arseni Trioxidum, U. S. P -fa-fa S r - (0.001-0.003 gm.). 

Liquor Acidi Arsenosi, U. S. P. (contains 

I per cent, of arsenic trioxid and 5 per 

cent, of diluted hydrochloric acid) . . . 1-5 rnin. (0.06-0.3 ex.). 
Liquor Potassii Arsenitis, U. S. P.( Fowler's 

Solution : contains the equivalent of I 

per cent, of arsenic trioxid and 3 per 

cent, of compound tincture of lavender), 1-5 min. (0.06-0.3 c.c). 

Sodii Arsenas, U. S. P ^-\ (0.004-0.008 gm.). 

Sodii Arsenas Exsiccatus, U. S. P. ... fa-fa gr. (0.002-0.005 gm.). 
Liquor Sodii Arsenatis, U. S. P. (Pear- 
son's Solution ; contains I per cent, of 

exsiccated sodium arsenate) 1-5 min.(o.o6-o.3 c.c). 

Arseni Iodidum, U. S. P fa~fa g r - (0.002-0.006 gm.). 

Liquor Arseni et Hydrargyri Iodidi, U. 
S. P. (Donovan's Solution : contains I 

per cent, each of arsenous iodid and 

mercuric iodid) 1-5 min. (0.06-0.3 c.c). 

ARSENI TRIOXIDUM, U. S. P. 

(Arsenic Trioxid ; Arsenous Acid ; White Arsenic ; As 2 3 .) 

Arsenic trioxid occurs either as an opaque, white, amorphous 
powder, or as heavy, amorphous masses of a translucent, 
glass-like appearance. .It has neither odor nor taste. When 
thrown on hot coals it volatilizes without melting, and emits a 
strong, garlicky odor. In the presence of water it becomes 
arsenous acid (H 3 As0 3 ). It is soluble in from 30-80 parts of 
cold water, slightly soluble in alcohol, and soluble in about 
5 parts of glycerin. The dose is from qq-Jo g r - (0.001-0.003 
gm.). 

Physiologic Action. — Local Action. — On mucous mem- 
branes and denuded surfaces arsenic trioxid, in concentrated 
form, acts as a powerful and painful caustic. If it is applied 
over large surfaces a sufficient quantity may be absorbed to 
produce systemic poisoning. 

Circulation. — In therapeutic doses, beyond increasing 
slightly the pulse-rate, arsenic exerts but little influence on 
the circulation. Toxic doses, however, lessen the frequency 
of the pulse and lower the blood-pressure. The fall of 
blood-pressure appears to be due to depression of the heart 
and of the vasomotor nerves, especially of those branches dis- 
tributed to the blood-vessels of the abdominal organs. 

Blood. — In health arsenic has little or no action on the 
blood, but in certain forms of anemia, especially pernicious 
anemia, it often increases decidedly the number of erythrocytes. 
The view that the blood improvement is due to stimulation of 
the bone-marrow receives some support from the experimental 
researches of Stockman and Grieg, who found that arsenic in- 



ARSE NUM. 307 

creased the vascularity of the marrow and led to a replace- 
ment of fat by red corpuscles. In some cases of poisoning 
there is marked disintegration of the red blood-cells. 

Nervous System. — Clinical experience indicates that in 
medicinal doses arsenic exerts a stimulant influence upon the 
nervous system. In frogs toxic doses cause a rapid paralysis, 
which appears to be mainly of centric origin. In man nervous 
phenomena occur in both acute and chronic poisoning, but 
they are especially pronounced in the latter. The paralysis of 
chronic poisoning is, in the majority of instances, the result of 
a polyneuritis similar to that produced by other toxic agents ; 
in a few cases, however, paralysis of spinal origin has been 
observed. 

Alimentary Canal. — In minute doses arsenic stimulates the 
appetite and favors digestion. Large doses have an irritant 
effect, and excite colicky pains, vomiting, and diarrhea. 

Effect on Metabolism. — It is generally conceded that ar- 
senic in therapeutic doses favorably influences nutrition, but 
the manner in which this is accomplished is not understood. 
Toxic doses have a profound effect upon tissue-metabolism. 
They increase proteid disintegration, augment the nitrogenous 
output, lessen oxidation of the tissues, and cause fatty changes 
in the epithelium of the alimentary canal, and, to a less extent, 
in the liver, heart, and kidneys. 

Elimination. — Arsenic passes out of the body very slowly ; 
most of it escapes in the urine, but traces may be detected in 
the other secretions. 

Action on Lower Organisms. — While arsenic will readily 
kill insects and worms, it is not very destructive to the lowest 
forms of animal and plant life. 

Toxicology. — Acute arsenical poisoning is characterized by 
severe abdominal pains, vomiting and purging of " rice-water " 
and, perhaps, bloody material, persistent thirst, oliguria, mus- 
cular cramps, dyspnea, cyanosis, and collapse. Death, which 
usually occurs in from one to three days, is often preceded by 
delirium, convulsions, and coma. If recovery follow, the symp- 
toms of acute poisoning may be slowly replaced by those of 
chronic poisoning. Occasionally cases are encountered in 
which the symptoms depart somewhat from the usual type ; 
thus there may be a rapid termination in collapse or coma 
without any preceding abdominal symptoms ; sometimes a 
temporary remission in the symptoms occurs about the third 
day, and this is followed, as in the case of phosphorus poison- 
ing, by jaundice and delirium ; again, there may be, in addition 
to the abdominal symptoms, an extensive urticarial or vesiculo- 
papular rash. 



308 AL TERA TIVES. 

It is difficult to fix upon the minimum fatal dose of arsenic 
trioxid, since much that is ingested often escapes absorption. 
According to Taylor, about 2 gr. (0.13 gm.) is the minimum 
fatal dose for an adult ; but cases are on record in which very- 
large doses, even 1-2 ounces (30.0-60.0 gm.), have been 
swallowed without destroying life. 

After death from arsenic macroscopic changes are apparent 
in the stomach and upper bowel. The mucous membrane is 
swollen, congested, and more or less eroded. Microscopic ex- 
amination of the organs reveals fatty degeneration in the epi- 
thelium of the alimentary canal, and in the liver, kidneys, and 
muscles. The erosion of the stomach cannot be the result of 
a local action, since it has occurred after the hypodermic injec- 
tion of the poison and after its introduction through a wound, 
when only minute quantities could have reached the stomach. 
Moreover, arsenic lacks the power possessed by corrosive 
poisons of uniting with proteid matter to form an albuminate. 
The action of the drug in inducing cellular death appears to 
be a specific one, and in the present state of our knowledge 
no satisfactory explanation of it can be given. 

Treatment of Acute Poisoning. — The stomach should be 
emptied by means of the stomach-pump or by an emetic. The 
best chemical antidote is the recently prepared ferric hydroxid 
or ferric hydroxid with magnesia (see p. 293), administered 
while still moist, in doses of a tablespoonful or more every ten 
or fifteen minutes. These compounds are in themselves harm- 
less and act by forming insoluble arsenites. Dialyzed iron, as 
it liberates a certain amount of free ferric hydroxid in the 
stomach, is also antidotal. As in poisoning from other irri- 
tants, diluents, demulcents, and opiates are usually indicated. 

Chronic arsenical poisoning may be a sequel of acute poison- 
ing, may follow the prolonged use of the drug for medicinal 
purposes, may result from the use of foods or liquors contam- 
inated with arsenic, may occur from the constant inhalation of 
dust arising from wall-paper or other fabrics containing arsen- 
ical pigments, or may be acquired by workers in arsenic mines 
or in factories in which fumes of the metal are formed. It 
may be manifested by gastro-enteritis, conjunctivitis, and 
catarrh of the upper air-passages, anemia, peripheral neuritis, 
and various cutaneous lesions. Polyneuritis from the medic- 
inal use of arsenic is by no means infrequent. It is most 
commonly observed in children, to whom the drug is being 
given for chorea. Railton has reported 4 cases in which the 
paralytic phenomena did not appear until from one to three 
weeks after the drug had been discontinued. The recent 



ARSENUM. 309 

endemic of chronic arsenical poisoning occurring in Manches- 
ter, England, in which over 4000 beer-drinkers were affected, 
was traced to the presence of arsenic in the glucose used for 
brewing. The sulphuric acid employed in making the glucose 
contained from 1.4 per cent, to 2.6 per cent, of arsenic trioxid, 
while the beer contained from \ to 3 gr. (0.016-0.2 gm.) per 
gallon (4.0 L.). In this endemic gastro-intestinal symptoms 
were not .marked, the chief phenomena being numbness and 
tingling in the hands and feet ; a sense of burning in the feet, 
and painful flushing, resembling erythromelalgia ; and certain 
skin-lesions, consisting of pigmentation resembling Addison's 
disease', herpes zoster, hyperidrosis, hyperkeratosis of the 
palms and soles, and pemphigoid eruptions. 

Besides hyperkeratosis of the hands and feet, prolonged 
arsenical medication may result in other lesions of the skin 
indicative of increased cellular proliferation. Thus it may lead 
to corns, horny growths, multiple warts, and, perhaps, to 
epithelioma. Hartzell has collected 1 1 cases of epithelioma 
occurring in psoriasis, and apparently due to the prolonged 
use of arsenic. 

Tolerance. — Under certain conditions, which are not well 
understood, the prolonged use of arsenic, instead of causing 
chronic poisoning, may result in the establishment of a toler- 
ance for the drug. In some parts of Austria it is a custom 
among many of the peasants to take gradually increasing 
doses of arsenic, under the belief that it improves the com- 
plexion and increases the endurance. According to Knappe, 
so much as 5 or 6 grains (0.3-0.4 gm.) are sometimes taken 
at a single dose without harm. The practice, however, even 
among these peasants, is not altogether free from risk, and in 
other countries it is the exception, rather than the rule, for the 
continued administration of arsenic not to be followed by 
untoward effects. 

Therapeutics. — Locally, arsenic trioxid is used success- 
fully as a caustic in removing from the skin circumscribed, 
superficial new growths, such as lupus and epithelioma, espe- 
cially the latter. For this purpose a paste made by adding 
equal parts of the trioxid and acacia to a saturated solution 
of cocain hydrochlorid is used. This should be spread over 
the diseased surface, and allowed to remain for from twenty- 
four to forty-eight hours, when a poultice may be applied to 
remove the slough. It is generally not advisable to spread 
the paste over a larger area than a square inch at one time. 

Internally, arsenic is employed empirically in a number of 
quite diverse pathologic conditions. After iron, it is the most 



310 AL TERA TIVES. 

effective drug we have in anemia. In pernicious anemia 
Fowler's solution, although not curative, is our best remedy. 
When well borne, the dose should be gradually increased, so 
that at the end of three or four weeks the patient is taking 
from 10-15 min. (0.6-1.0 c.c.) or more, three times a day. 
Fowler's solution is also a valuable remedy in Sydenham's 
chorea or St. Vitus 's dance. To be effective, however, it must 
be given in ascending doses until symptoms of saturation 
appear. Neuralgia that is dependent upon anemia is often 
benefited by arsenic. In pulmonary tuberculosis no general 
tonic, with the exception of cod-liver oil, is so serviceable. 
The drug has a long-standing reputation as a remedy in dia- 
betes mellitus. While it is not nearly so efficacious as opium, 
it may be tried in the mild forms of the disease. It is a good 
alterative in chronic rheumatism, chronic gout, and rheumatoid 
arthritis. In bronchial asthma it is sometimes very efficient, 
although it is not so reliable as potassium iodid. According 
to Murray, it is especially useful in the asthma of children and 
of old emphysematous persons. 

Both Bramwell and Balfour have spoken in the highest 
terms of the prolonged use of arsenic GoQ -gV gr. — 0.0006- 
O.0012 gm.) in myocardial degeneration and angina pectoris. 
In these cases it may be combined advantageously with 
strychnin, and sometimes also with digitalis. 

In malaria it is a useful adjuvant to quinin. It probably 
exerts no destructive influence upon the parasite, but when 
employed after the subsidence of the paroxysms, it proves a 
valuable blood-restorer. 

Arsenic has been found efficacious in certain diseases of the 
digestive tract. It is often very useful in that obstinate affec- 
tion know as " geographic tongue',' in which whitish, circinate 
patches appear upon the tongue and creep from one part to 
another. In some cases of gastralgia it acts most happily. 
Ringer has derived great benefit from the use of Fowler's 
solution — a drop shortly before meals — in the morning vomit- 
ing of drunkards, and in cases of so-called irritative dyspepsia, 
in which the tongue is furred and its papillae are red and 
prominent. The same treatment is also highly recommended 
in that form of indigestion which is characterized by an uncon- 
trollable desire to evacuate the bowel immediately after taking 
food. 

The administration of arsenic sometimes gives very gratify- 
ing results in certain chronic inflammatory skin diseases of a 
sluggish type. It is especially useful in psoriasis, pemphigus, 
and chronic erythematous, squamous, and papular eczema. The 



ARSENUM. 311 

drug is contraindicated when the inflammatory process is of 
an acute or active type. It is a common practice to give 
Fowler's solution in combination with bromids to prevent the 
outbreak of acne. Ewald has confirmed the observation 
originally made by Mabille that arsenic obviates to a great 
extent the unpleasant symptoms excited by thyroid medica- 
tion. 

Administration. — As persons vary considerably in their 
susceptibility to the action of arsenic, it is always well to begin 
with small doses of the drug and to increase them gradually. 
Pufrmess under the eyes, especially noticeable in the morning, 
and looseness of the bowels, with colicky pains, are the usual 
indications of saturation. For pills, arsenic trioxid is generally 
selected, and for solutions, the solution of potassium arsenite. 
When a very decided impression is desired, as in chorea and 
pernicious anemia, the best preparation to employ is Fowler's 
solution, and this should be prescribed by itself, so that changes 
in the doses can be readily made from day to day. When 
arsenic is prescribed for its constitutional effect, it should be 
given invariably after meals. When it is not tolerated by the 
stomach, it may be given subcutaneously in the form of sodium 
arsenate. 

The following formulae will illustrate the manner of pre- 
scribing the drug in combination : 

R Arseni trioxidi, gr. ss (0.03 gm.) ; 

Quininae sulphatis, gr. 1 (3.2 gm.) ; 

Ferri reducti, gr. xl (2.6 gm.) ; 

Pulveris capsici, gr. x (0.65 gm.). — M. 

Fiant pilulse No. xx. 

Sig. One after meals. ( Malaria after the arrest of the paroxysms. ) 

R Liquoris potassii arsenitis, fgiss (5.5 c.c); 

Sodii salicylates, gv (20.0 gm.) ; 

Glycerini, f t ^j (30.0 c.c.) ; 

Aquae menthae piperitae, q. s. ad. f^iv (118.0 c.c). — M. 
Sig. A teaspoonful in water, gradually increased to a dessertspoon- 
ful, after meals. {Diabetes mellitus.) 

Incompatibles. — Salts of iron, silver, copper, and ammo- 
nium, magnesia, lime, and tannic acid. 

Arseni Iodidum, U. S. P. — Iodid of arsenic occurs in 
orange-red, glossy crystals, having the odor and taste of iodin. 
It is soluble in water and alcohol. The dose is from 3 1 Q - 1 1 () gr. 
(0.002-0.006 gm.). It has been found useful in tuberculous 
adenitis or scrofula. Saint-Phillippe has employed it with suc- 
cess in the troublesome bronchitis of strumous children. He 
recommends 5 min. (0.3 c.c.) of a 1 per cent, solution, 
gradually increased to 10-15 min. (0.6-1.0 c.c), with meals. 



312 ALTERATIVES. 

Aqueous solutions should be freshly prepared and kept in a 
cool place, since they are prone to decompose into arsenous 
and hydriodic acids. 

Sodii Cacodylas. — Sodium cacodylate is an organic com- 
pound derived from cacodylic acid or dimethyl arsenic. It 
is a soluble, deliquescent, tasteless solid, containing about 
50 per cent, of arsenic. Like other organic compounds of 
arsenic it is only feebly toxic — according to Renaut, 15 gr. (1.0 
gm.) injected intravenously into a rabbit does not cause death. 
It has been employed medicinally in the same conditions in 
which the inorganic preparations of arsenic have been found 
useful. The dose is from J— ij gr. (0.02-0.1 gm.) hypodermi- 
cally two or three times a day. T. R. Fraser has shown that 
cacodylates are inert because no dissociating influence to 
which thay are subjected in the tissues is able to liberate 
from them the active arsenic ion. He was never able by 
the usual tests to detect arsenic in the urine after their 
administration. His experiments prove what might confi- 
dently have been anticipated, that if arsenic is so firmly united 
with other bodies as to be incapable of producing toxic action, 
it is not capable of producing therapeutic influence. If admin- 
istered by the mouth, however, cacodylates may become poi- 
sonous by meeting with reducing agents in the alimentary canal. 
Murrell has reported a case of poisoning in a tuberculous 
patient from the administration of sodium cacodylate by the 
mouth in doses of 1 gr. (0.065 gm.) twice daily. The toxic 
symptoms appeared after the eleventh dose. 

Atoxyl. — This is an organic compound of arsenic acid 
(sodium aminophenyl arsenate) with one hydroxyl radical of 
the acid replaced by a molecule of anilin. It contains about 
26 per cent, of arsenic. It appears as a white powder having 
a slightly saline taste, soluble in 6 parts of water. The dose is 
from \ to I gr. (0.02-0.065 gm.), hypodermically, every other 
day. Atoxyl acts like other arsenical compounds, but it is less 
irritant, and, owing to its slow decomposition, less toxic. It is 
capable, however, of producing poisonous effects, and Koch, 
Marie, Bardet, and others have reported a number of cases in 
which more or less serious visual disturbances occurred under 
its administration. It is said to have given good results in the 
various conditions in which arsenic generally has been found 
beneficial, and has been especially recommended in syphilis 
with marked cachexia and sleeping sickness. 

I4quor Arseni Brotnidi. — This preparation, which is also 
known as Clemens' solution, is not, as its name implies, a solu- 
tion of the bromid of arsenic, since the latter is decomposed in 



POTASS// /OD/JDUM. 313 

the presence of water, but rather a solution of arsenate and 
bromid of potassium. It is made by boiling 73 gr. (47.3 gm.) 
each of arsenic trioxid and of potassium bicarbonate in 2 fl. oz. 
(59.14 c.c.) of water until solution is effected ; allowing to cool, 
adding 10 fl. oz. (295.73 c.c.) of water, then H7gr. (7.581 gm). 
of bromin, and finally enough water to make 16 fl. oz. (473.17 
c.c). The solution represents about 1 per cent, of arsenic tri- 
oxid. The dose is from 1-5 min. (0.06-0.3 c.c), well diluted, 
after meals. It has been largely used in the treatment of 
diabetes mellitus, but with less success than opium, salicylic 
compounds, or antipyrin. 

Cupli Arsenis. — Arsenite of copper is a yellowish-green 
crystalline powder, slowly soluble in water. Under the name 
of Paris green or Scheele's green it is much used as an insect 
poison and as a pigment for paper, cotton fabrics, artificial 
flowers, etc. Cases of poisoning from this salt of copper have 
been of frequent occurrence. The antidotes are the same as 
those to arsenic trioxid. The therapeutic dose is from -3-g-g— 
yj-g- gr. (0.0002-0.00064 gm.), well diluted. It has been very 
highly recommended as an intestinal antiseptic in the diarrhea 
of childhood, when the stools are copious, green, and offensive. 

POTASSII IODIDUM, U. S. P. 

(Potassium Iodide, KI.) 

Potassium iodid occurs as colorless, transparent or translu- 
cent crystals, or as a white granular powder, having a pun- 
gent, saline taste. It is soluble in 0.7 part of water, 2.5 parts 
of glycerin, and 12 parts of alcohol. The usual dose is from 
5-10 gr. (0.3-0.65 gm.), well diluted, thrice daily; but in 
syphilis often three or four times this amount may be given 
with advantage. 

Preparation. 
Unguentum Potassii Iodidi, U. S. P. (contains 10 per cent, of potassium 
iodid and 0.6 per cent, of potassium carbonate). 

Physiologic Action. — In health a single, moderate dose 
of potassium iodid produces no demonstrable effects beyond a 
slight increase in the secretion of urine and, perhaps, some 
disturbance of the stomach. The drug is rapidly absorbed 
from all parts of the digestive tract, and reappears in the secre- 
tions in less than fifteen minutes after its ingestion. The larger 
portion is eliminated through the kidneys, but small quantities 
escape in the saliva, tears, milk, and perspiration. It is likely 
that a small portion is retained for a time in the body, and 
that its continuous administration may result in accumulation. 



314 AL TERA TIVES. 

Large doses of potassium iodid cause burning in the stomach, 
nausea, vomiting, and diarrhea. The continuous use of the 
drug is usually followed, sooner or later, by a group of symp- 
toms known as iodism. This condition has been attributed to 
the irritant effects of free iodin, into which a portion of the 
iodid appears to be converted. Its manifestations are most 
commonly associated with the mucous membrane of the res- 
piratory tract and with the skin, and consist of frontal head- 
ache, lacrimation, running at the nose, sneezing, soreness of 
the throat, an increased flow of saliva, and, later, of a generalized 
acneiform eruption on the skin. More rarely the eruption is 
of an erythematous, purpuric, or bullous character. Parotitis 
and intense dyspnea from inflammatory edema of the larynx 
have occasionally been observed. In some instances symptoms 
suggesting Graves' disease have developed, such as tremors, car- 
diac palpitation, sweating, and loss of weight. It is not improb- 
able that the last-named symptoms owe their origin to an in- 
fluence exerted by the iodid on the thyroid gland. Profound 
cachexia, atrophy of the mammae or testicles, paralysis, and blind- 
ness have also been reported as occurring from the prolonged 
use of iodids. The amount of the drug required to induce iodism 
varies considerably in different subjects. Daily doses of from 
200-300 gr. (13.0-20.0 gm.) are sometimes well borne, and, on 
the other hand, doses of from 2-3 gr. (o. 1 3-0.2 gm.) a day may 
soon excite intense discomfort. Russell has reported a case in 
which 5 doses of 4 min. (0.25 c.c.) of the syrup of ferrous 
iodid with 2 gr. (0.13 gm.) of potassium iodid, over a period 
of three days, caused acute iodism with fatal termination, in a 
man of sixty-eight years, suffering from rheumatoid arthritis. 
Patients with chronic Bright's disease are often extremely 
intolerant. Syphilis does not always confer immunity. 

Therapeutics. — Potassium iodid is of value in a variety 
of morbid conditions, but the study of its action on healthy 
subjects has thus far failed to throw much light upon the 
manner in which its good effects are accomplished. Its best 
effects are observed in syphilis, in which disease its efficacy is 
equal to that of mercury. In the tertiary period it is more 
valuable than mercury, and in the late secondary period it is 
an excellent adjuvant. It should be given in ascending doses 
until improvement follows or symptoms of iodism appear. To 
secure permanent results, the treatment must be continued 
for six months or a year. In parasyphilitic affections — loco- 
motor ataxia, paretic dementia, and arteriosclerosis — the iodid 
should always be tried, though, of course, no good can accrue 
from its use if there has been much destruction of tissue. 



POTASSII IODIDUM. 315 

Various opinions are held as to the value of potassium iodid 
in chronic interstitial inflammations, like cirrhosis of the liver, 
chronic interstitial ?iephritis } and sclerosis of the spinal cord, 
when a syphilitic origin can be excluded. The author is of 
the opinion that though the drug is of doubtful service, it 
ought to be tried. Only small doses, however, should be given, 
and these should be withdrawn on the slightest evidence of in- 
tolerance. In subacute and chronic rheumatism and in chronic 
gout it sometimes proves beneficial. It is generally believed 
that it aids in the absorption of the effusion in serous pericar- 
ditis and pleurisy. It is the most reliable remedy that we pos- 
sess in bronchial asthma to prevent the return of the parox- 
ysms. In chronic bronchitis, when the sputum is composed of 
thick, viscid mucus, it may be combined advantageously with 
expectorants. 

In doses of from 10-20 gr. (0.65-1.3 gm.) thrice daily it is 
very beneficial in aortic aneurysm, ; even if it does not retard 
the progress of the disease, it nearly always lessens the pain. 
It is said to act by lessening the viscosity of the blood, but 
this is doubtful. It certainly does not lower the blood-pressure. 
In angina pectoris no remedy with the exception of the nitrites 
is so useful in preventing recurrence of the attacks. To be 
effectual it should be given in daily doses of from 30-45 gr. 
(2.0-3.0 gm.) for several months. According to Osier, the 
patients who stand the treatment well are the robust, middle- 
aged men, in whom the angina is the sole symptom. 

In chronic metallic poisoning, especially from lead and mer- 
cury, potassium iodid is apparently efficacious. In large doses 
continued over long periods of time it has given very good 
results in many cases of actinomycosis in man. 

Administration. — Individual susceptibility to the iodids 
varies remarkably and idiosyncrasies are frequently encoun- 
tered. Children generally bear the drug much better than 
adults. The initial dose should always be small, and the 
amount gradually increased as the tolerance of the patient 
permits. No drug is of much value in preventing iodism when 
the tendency to it is pronounced, but the tincture of bella- 
donna (3-5 min. — 0.2-0.3 c.c.) will sometimes relieve the coryza, 
and Fowler's solution (1-2 min. — 0.06-0.12 c.c), the acne and 
indigestion. Iodids should always be given after meals and 
well diluted. The unpleasant taste can be disguised with 
compound syrup of sarsaparilla. A convenient method of 
prescribing potassium iodid is in the form of a saturated aque- 
ous solution, so prepared that 1 min. (0.06 c.c.) will contain 
1 gr. (0.065 gm.) of the salt. As prescribing the iodid and 



316 ALTERATIVES. 

water, ounce for ounce, results in a solution much weaker 
than the one indicated, Hynson suggests the following plan : 
Dissolve 480 gr. (31.1 gm.) of the salt in 5 J dr. (20.34 c.c.) 
of hot water, and then make up the solution to 8 dr. (29.57 c.c.) 
with water. This results in a solution containing 1 gr. (0.065 
gm.) to a minim (0.06 c.c). A drop from a medicine dropper 
will contain a little less than 1 gr. (0.065 gm.). If taken in 
milk, most patients do not find the solution disagreeable. 
When not tolerated by the stomach, potassium iodid may be 
given as an enema in milk. 

Incompatibles. — Mineral acids and salts, alkaloids, and 
spirit of nitrous ether. Potassium iodid is often added in 
excess to solutions of corrosive sublimate to form the soluble 
double iodid of mercury and potassium. 

SODII IODIDUM, U. S. P. 

(Sodium Iodid; Nal.) 

Sodium iodid occurs in colorless, cubical crystals or white 
crystalline powder, of a bitter, saline taste. On exposure to 
moist air it deliquesces and becomes sodium carbonate and 
free iodin. It is soluble in 0.5 part of water and in 3 parts of 
alcohol. The dose is from 5-20 gr. (0.3-1.3 gm.) or more, 
well diluted. It has the same therapeutic value as the potas- 
sium salt, but it is sometimes better borne by the stomach. 

AMMONII IODIDUM, U. S. P. 

(Ammonium Iodid ; NHJ.) 

Ammonium iodid occurs in minute colorless, cubical crystals 
or white granular powder, of sharp, saline taste. On exposure 
it attracts moisture from the air, and becomes yellowish-brown 
from the loss of ammonia and the liberation of iodin. It is 
soluble in 0.6 part of water and in 9 parts of alcohol. The 
dose is from 3-15 gr. (0.2-1.0 gm.) or more, well diluted. 
Excepting that it is somewhat more irritating to the stomach 
it has the same properties as potassium iodid. 

STRONTII IODIDUM, U. S. P. 

(Strontium Iodid ; Srl 2 -f 6H 2 0.) 

Strontium iodid occurs in colorless or faintly yellow, hex- 
agonal plates, deliquescent, and of bitterish, saline taste. It is 
soluble in 0.5 part of water. The dose is from 5-20 gr. (. ^ 
1.3 gm.) or more, well diluted. While less irritating and less 
prone to induce iodism than potassium iodid, it does not seem 
to be so powerful as the latter salt. 



IODUM. 317 

PLUMBI IODIDUM, U. S. P. 

(Leadlodid; Pbl 2 .) 

Lead iodid is a heavy, bright yellow powder, odorless and 
tasteless, and permanent in the air. It is almost insoluble in 
water. The dose is from J— 3 gr. (0.03-0.2 gm.). 

Preparation. 
Unguentum Plumbi Iodidi (10 per cent.). 

Iodid of lead is rarely used internally. Externally the oint- 
ment makes an excellent resolvent application for tuberculous 
lymphatic glands and other forms of nonsuppurative adenitis. 
It should be applied very thoroughly and with gentle friction. 

ACIDUM HYDRIODICUM. 

(Hydriodic Acid; HI.) 

Hydriodic acid is official as diluted hydriodic acid {Acidum 
Hydriodicum Dilutum, U. S. P.), which contains 10 per cent, 
by weight of the absolute acid, and as the syrup of hydriodic 
acid (Syrupus Acidi Hydriodici, U. S. P.), which contains 1 per 
cent, by weight of the absolute acid. The action of these prep- 
arations is feeble, but resembles that of the iodids. The 
dose of the diluted acid is from 5-10 min. (0.3-O.6 c.c.), and 
of the syrup \-2 fl. dr. (2.0-8.0 c.c). 

IODUM, U. S. P. 

(Iodine ; I.) 

Iodin is a non-metallic element obtained chiefly from the 
ashes of seaweed. It occurs in heavy, bluish-black, friable 
crystals, having a metallic luster, a peculiar odor, and a sharp, 
acrid taste. On heating it emits a violet-colored vapor. It is 
soluble in 5000 parts of water, in 10 parts of alcohol, and 
freely soluble in ether, chloroform, and solutions of potassium 
iodid. 

Preparations. Dose. 

Tinctura Iodi, U. S. P. (7 per cent.) 1-5 min. (0.06-0.3 c - c -)- 

Liquor Iodi Compositus, U. S. P. (Lugol's solu- 
tion : 5 per cent, of iodin in a 10 per cent, 
solution of potassium iodid) I-IO min. (0.06— 0.6 c.c. ). 

Unguentum Iodi, U. S. P. (4 per cent, of iodin 
and 4 per cent, of potassium iodid). 

Physiologic Action. — When applied to the skin, iodin 
stains it a yellowish-brown color and causes burning and itch- 
ing. Strong solutions produce vesication. Mucous mem- 
branes are especially sensitive to its irritant action. Injections 
beneath the skin or into serous .sacs excite intense pain and 



3 1 8 AL TERA TIVES. 

severe inflammatory reaction. When taken internally, it is 
rapidly absorbed in the form of iodids and soon reappears in 
all the secretions of the body. The bulk of it is eliminated in 
the urine, also in the form of iodids. In medicinal doses iodin 
exerts the same influence as potassium iodid, and if given con- 
tinuously, induces all the phenomena of iodism (p. 314). Single 
large doses produce gastro-enteritis, respiratory failure, and 
collapse. Anuria and albuminuria have also been observed. 
Cases of fatal poisoning have been reported from its injection 
into large cysts and also from its too free use externally. 

The treatment of acute iodin-poisoning consists in evacuating 
the stomach, administering starch or starchy foods (flour, arrow- 
root) as antidotes, and maintaining the respiration and circula- 
tion by hypodermic injections of alcohol, strychnin, digitalis, 
and ammonia. 

Therapeutics. — Iodin is a useful counterirritant in con- 
ditions requiring a mild but persistent effect. The tincture 
may be applied externally in pleurisy, bronchitis, laryngitis, 
synovitis, arthritis, neuritis, muscular rheumatism, and similar 
inflammatory affections. It is best applied by means of a 
camel's-hair brush, one or two coats being painted over the 
part at intervals of a day or two. For children it should be 
diluted with 2 or 3 parts of alcohol. If the application proves 
too painful, the iodin should be removed with dilute alcohol, 
or, better, with a solution of potassium iodid, and the part 
dressed with starch jelly. 

Preparations of iodin are very efficacious in bringing about 
resolution in various forms of adenitis provided they are applied 
early and before suppuration has commenced. A broad ring 
may be painted with the tincture around the swelling, or the 
ointment may be thoroughly rubbed into it. A better plan, 
however, and one less likely to produce painful dermatitis, is 
to rub in a mixture of equal parts of the ointments of bella- 
donna and of lead iodid, and then to apply firm continuous 
pressure by means of a pad and a bandage. 

Ganglion, hydrocele, housemaid's knee, and spinal meningo- 
cele are often successfully treated by evacuating the fluid and 
then injecting tincture of iodin into the sac. Iodin was formerly 
much used, both internally and externally, in the treatment of 
simple goiter , hut thyroid extract has been found more efficacious. 
Injections of tincture of iodin are sometimes of value in reduc- 
ing cystic goiter. From 3-5 min. (0.2-0.3 c.c.) should be in- 
jected into different parts of the tumor at intervals of three or 
four days. Local applications of iodin have long been held in 
high repute in certain chronic catarrhal processes attended by 



IODOFORMUM. 319 

glandular hypertrophy, such as rhinitis, pharyngitis, and endo- 
metritis. 

In chilblain an application of tincture of iodin and glycerin, 
equal parts, acts very favorably. Iodin has been used inter- 
nally in the form of Lugol's solution in syphilis, tuberculous 
adenitis, and goiter, but on account of its irritant properties it 
is far less serviceable than the iodids. 

Various attempts have been made to lessen the irritant effects 
of iodin by combining it with albumin or fat. The preparation 
known as iodipin represents, perhaps, the most successful of 
these attempts. It is an addition-product of iodin (10 per cent. 
or 25 per cent.) and oil of sesame, which, according to Win- 
ternitz, is not decomposed in the stomach, but in the intestine. 
The 10 per cent, preparation is administered by the mouth in 
doses of J— 2 fl. dr. (2.0-8.0 c.c). It is generally well borne, 
but its oily taste frequently proves objectionable. The 25 per 
cent, iodipin is used for subcutaneous injection, about J-i fl. 
dr. (2.0-4.O c.c), slightly warmed, being injected daily between 
the skin and muscle of the gluteal region. 

Incompatibles. — Alkaloids, mineral salts, ammonia, car- 
bonates, starch, and mucilage of acacia. It acts violently upon 
turpentine and many other volatile oils. Tincture of iodin is 
also incompatible with aqueous preparations. In the so-called 
" colorless solutions of iodin " the iodin is replaced by iodids. 

IODOFORMUM, U. S. P. 

(Iodoform; CHI,.) 

Iodoform, or tri-iodid of methane, is methyl with 3 atoms of 
hydrogen displaced by 3 of iodin. It is made by heating in a 
closed vessel iodin, alcohol, sodium hydrate, and water. It 
occurs in small, yellow, hexagonal crystals, having a peculiar 
penetrating odor, and a sweetish, iodin-like taste. It is freely 
soluble in ether, chloroform, and oils, soluble in about 47 parts 
of alcohol, and very feebly soluble in water. It contains more 
than 95 per cent, of iodin. The dose is from 1-3 gr. (0.06- 
0.2 gm.) in pill. 

Preparation. 

Unguentum Iodoformi, U. S. P. (10 per cent.). 

Physiologic Action. — Upon mucous membrane and raw 
surfaces, especially the latter, iodoform acts as a mild anes- 
thetic. It is readily absorbed from wounded surfaces, partly 
as iodin, which it liberates in the presence of moist organic 
matter, partly as albuminous compounds of iodin, and partly, 
probably, as iodoform. Shortly after absorption iodin appears 



320 ALTERATIVES. 

in all the secretions ; elimination, however, is mainly effected 
through the kidneys, which slowly excrete the drug in the form 
of iodids. When absorbed too freely it induces an intoxication, 
which not infrequently proves fatal. The symptoms of poison- 
ing somewhat resemble those of cerebral meningitis, and include 
malaise, headache, mental depression, contraction of the pupils, 
the taste of iodoform in the mouth, nausea and vomiting, a 
very rapid pulse, delirium with hallucinations, stupor, and coma. 
In some cases there has been, in addition, high fever, and in 
others, a diffuse erythematous rash. Postmortem examination 
shows fatty degeneration of the organs and sometimes conges- 
tion of the cerebral meninges. As neither iodin nor iodids in 
overdoses cause cerebral symptoms, it is probable that the 
latter result from the action of iodoform itself. Old, anemic 
patients, especially sufferers from Bright's disease, are more 
readily poisoned than the young and robust. 

Although the favorable action of iodoform on infected 
wounds can no longer be disputed, the manner of its operation 
is still obscure. It has little or no germicidal power, but it 
may act by retarding germ-growth through the iodin which it 
liberates, by inhibiting serous exudation and thus depriving 
the organisms of nourishment, or by neutralizing the toxins 
formed by bacteria. 

In some persons the local application of iodoform proves 
irritating, and gives rise to a severe pustular or erythematous 
eruption. 

Treatment of Poisoning. — The indications are to suspend 
the applications, to sustain the strength of the patient, and 
to favor elimination of the drug by means of subcutaneous 
injections of normal salt solution and the administration of 
alkaline diuretics. 

Therapeutics. — Iodoform is extensively employed as a 
local application in infected wounds. In various ulcers — syphil- 
itic, chancroidal, and tuberculous — it is very efficient. In the 
form of iodoform gauze it makes an excellent packing for deep 
wounds, sinuses, ftstidce, and the rectal, vaginal, and nasal cav- 
ities. Cold abscesses and tuberculous joints are often successfully 
treated by injecting into them, once a week, iodoform (10 per 
cent.) in sterile olive oil or glycerin or iodoform (5 per cent.) 
in ether, to the amount of \- 3 fl. oz. (15.0-90.0 c.c). The 
iodoform should always be sterilized by soaking it for several 
days in a solution of 1 : 1000 of corrosive sublimate and then 
thoroughly washing in sterilized water. 

As a local analgesic it is particularly useful in relieving the 
pain and dysphagia of tuberculous laryngitis, in which affection 



IOD O FOR MUM. 3 2 1 

it may be employed by insufflation, either in pure form (2-3 
gr. — O.13-O.2 gm.) or mixed with morphin (yV~rV S r - — 0.004- 
0.005 g m 0- Suppositories of iodoform (3 gr. — 0.2 gm.) are 
of service in pai?iful hemorrhoids and in fissure of the anus. 

Semmola, Dreschfeld, Foxwell, and others have spoken 
very highly of the internal use of iodoform (6-12 gr. — 0.4-0.8 
gm. daily) in pulmonary tuberculosis, but the treatment has 
gone out of vogue. While many agents have been recom* 
mended for disguising the disagreeable odor of iodoform, none 
has proved very successful ; the best, however, are the volatile 
oils, such as bergamot, fennel, anise, and cumarin, the odorous 
principle of Tonka bean. 

IODOLUM, U. S. P. 
(Iodol; Tetra-iodo-pyrrol ; C 4 I 4 NH.) 

Iodol is prepared by acting upon pyrrol, a principle obtained 
from bone oil with iodin. It contains a little less than 90 per 
cent, of iodin, and appears as a yellowish, crystalline powder, 
free from odor and taste. It is almost insoluble in water, but 
it is freely soluble in alcohol, ether, and oils. 

It is used as a substitute for iodoform. Though much more 
costly than the latter, it has a decided advantage in being 
odorless. 

THYMOLIS IODIDUM, U. S. P. 
(Thymol Iodid ; Di-thymol-di-iodid ; Aristol; C 20 H 24 O 2 I 2 .) 

Thymol iodid, or aristol, is obtained by acting upon thymol 
in alkaline solution with iodin dissolved in potassium iodid. 
It contains about 45 per cent, of iodin, and appears as a brown- 
ish-red powder, tasteless and almost odorless. It is readily 
soluble in ether and oils, but it is insoluble in water. It is 
decomposed by heat, light, acids, alkalis, alcohol, and corro- 
sive sublimate. 

It is employed as a substitute for iodoform. While it has 
advantages in being odorless and less toxic than iodoform, it 
is more unstable, more costly, and less effective. It may be 
applied pure or dissolved in ether or oil. 

EUROPHEN. 

(Di-isobutyl-ortho-cresol-iodid ; C^H^CXJ. ) 

Europhen is obtained by precipitating an alkaline solution 
of isobutyl-ortho-cresol with a solution of iodin in potassium 
iodid. It contains 28 per cent, of iodin, and appears as a very 
bulky, yellow, amorphous powder, of an aromatic odor. It is 
insoluble in water and glycerin, but freely soluble in alcohol, 
ether, and oils. It is a good substitute for iodoform. 
21 



322 AL TERA TIVES. 

NOSOPHEN. 

( Tetra-iodo-phenol-phthalein ; ( C 6 H 2 I 2 OH ) 2 C 8 H 4 2 . ) 

Nosophen is obtained by the action of iodin on a solution 
of phenol-phthalein. It is a pale yellow, inodorous, and taste- 
less powder. It contains 60 per cent, of iodin. With bases it 
forms salts, the most important of which is the sodium salt 
(antinosiri). It differs from iodoform in being an active anti- 
septic and in not yielding its iodin to the tissues. 

HYDRARGYRUM, U. S. P. 

( Mercury ; Quicksilver ; Hg.) 

Mercury is a heavy, liquid metal, of a silvery luster, and 
without odor or taste. 

Physiologic Action. — When small doses of an unirritating 
preparation of mercury are given continuously for a certain 
length of time, the first effects are observed in the mouth. 
There are increased flow of saliva, fetor of the breath, soreness 
of the teeth when the jaws are brought forcibly together, and 
redness of the gums near the insertion of the teeth. If the 
drug is not withdrawn, salivation becomes excessive, the gums 
become swollen and spongy, the teeth loosen and fall out, the 
tongue and parotid glands enlarge, — the former sometimes to 
such an extent that it protrudes from the mouth, — and finally 
the soft tissues become ulcerated and the bones necrosed. 
The term ptyalism is applied to this group of symptoms. At 
the same time the general health is more or less affected. The 
patient becomes pale and loses flesh. Fever, chilliness, thirst, 
anorexia, nausea, vomiting, and purging may appear. 

The mercuric salts are more irritant and poisonous than the 
mercurous salts. The ingestion of a large dose of one of the 
former (corrosive sublimate) is speedily followed by intense 
burning in the esophagus, stomach, and abdomen, vomiting 
and purging of mucous and bloody material, anuria, or ischuria 
with albuminous urine, and profound collapse. Subsequently, 
if the patient survive the corrosive effects of the drug, ptyalism 
may develop from the absorption of the metal into the circula- 
tion. After death from acute mercury poisoning the mucous 
membrane of the alimentary canal is intensely inflamed and 
often deeply eroded. A diphtheric condition is sometimes 
observed. The kidneys are peculiarly affected. In addition 
to the evidences of acute parenchymatous degeneration, deposits 
of lime are found in the uriniferous tubules, especially the con- 
voluted ones. These chalky deposits, while not pathog- 
nomonic of mercurial poisoning, are very suggestive of it. 

Chronic mercurial poisoning is most frequently met with in 



HYDRARG YR UM. 323 

workmen who handle the metal or who are exposed to its 
fumes. Thus it occurs in makers of thermometers, mirrors, 
and scientific instruments. Occasionally it is induced by the 
prolonged use of mercury as a medicine. Its chief manifesta- 
tions are anemia, loss of flesh and strength, mental impair- 
ment, tremors similar to those of multiple sclerosis, motor 
palsies without atrophy of the muscles, gastro-intestinal dis- 
turbances, stomatitis, and salivation. 

The form in which mercury is absorbed has not been defi- 
nitely determined, but it is probable that the soluble prep- 
arations, at least, enter the circulation in the form of an 
albuminate. The metal is slowly eliminated through all the 
emunctories, but especially through the kidneys and bowel. 

In medicinal doses the insoluble preparations of mercury 
act as cathartics (see p. 209), producing copious, loose stools 
without much griping. They also increase the flow of urine 
(see p. 233), probably by directly stimulating the renal epi- 
thelium. It is generally assumed that they stimulate also the 
hepatic cells, and thus increase the flow of bile, but recent 
investigations have shown that they have no such action. 
Mercurials, especially when locally applied, have a decided 
influence upon inflammatory exudations of a serous or fibrinous 
character, often aiding materially in their solution and reab- 
sorption. That they have power to prevent or to lessen the out- 
pouring of inflammatory material is very doubtful. There is 
reason for believing that the bichlorid in minute doses { ^q $ 
gr. — 0.0006-0.001 gm.) causes an increase in the number of 
red blood-corpuscles, when the latter have been reduced from 
overwork, acute disease, or hemorrhage. Soluble forms of 
mercury, owing to the avidity with which they unite with pro- 
teids, are very destructive to bacteria and other low forms of 
life. Finally, the drug exerts a specific influence in syphilis, 
but the manner of its action is unknown. 

Untoward Effects. — Certain persons are exceedingly sus- 
ceptible to the influence of mercury. A dose of less than a 
grain (0.065 gm.) of calomel has been known to excite severe 
stomatitis, persisting for several weeks. An erythematous or 
eczematous rash occasionally follows its administration by the 
mouth or its application to the skin. Calomel should not be 
applied to mucous membranes or be taken internally while the 
patient is under the influence of potassium iodid, since the 
latter is eliminated in all secretions and readily forms with 
mercurous compounds the irritant mercuric iodid. 

Treatment of Poisoning. — Ptyalisin. — The administra- 
tion of mercury should be suspended as soon as the slightest 
tenderness of the gums manifests itself. The mouth should be 



3 H AL TERA TIVES. 

frequently rinsed with a saturated solution of potassium chlo- 
rate. In severe cases the affected parts may be painted with 
slightly diluted sulphurous acid or with a saturated solution 
of iodoform in ether. To check the excessive flow of saliva, 
atropin (yj-g- gr. — 0.0005 gm.) may be given once or twice a 
day. Morphin may be required at night to relieve pain and 
to secure sleep. Potassium iodid is recommended to aid in 
the elimination of the mercury. Tonics may be needed to 
combat the anemia and exhaustion. 

Acute Poisoning. — After evacuating the stomach, egg- 
albumen should be administered freely as an antidote. Opium 
is often required to allay the pain. 

Chronic Poisoning 1 . — The patient should be removed from 
the influence of the metal. Potassium iodid should be given to 
aid the elimination of the poison, and tonics to overcome the 
cachexia. Baths, massage, and electricity are useful adjuvants. 

Therapeutics. — Mercury is used as an antisyphilitic, a 
germicide, a cathartic, a diuretic, and an absorbent. 

Antisyphilitic. — Mercurials and iodids are the remedies 
relied upon to combat syphilis. Mercury should be given as 
soon as the diagnosis can be made with certainty, and con- 
tinued throughout the secondary stage. In the tertiary stage 
iodids are generally more serviceable, but mercury is not with- 
out effect, and a combination of the two drugs is often em- 
ployed with advantage. When very prompt effects are neces- 
sary, mercury should be given the preference. No matter 
which preparation of the metal is selected it should be given 
in ascending doses until the limit of tolerance is reached, when 
the dose should be cut down one-third or one-half, and this 
amount continued for a year or a year and a half. At the end 
of this time an iodid should be added, and the combination 
continued for about another year. The preparations of mer- 
cury most frequently prescribed in syphilis are the protiodid, 
biniodid, bichlorid, and mercury with chalk. 

Germicide. — The soluble preparations of mercury, although 
among the most powerful germicides known, have certain 
drawbacks. Thus they are highly toxic, they are irritating to 
the tissues, they are destructive to metal instruments, and in 
the presence of albuminous matters they are readily converted 
into insoluble and inert albuminates. Notwithstanding these 
drawbacks they are the most popular germicides for general 
surgical work. Of the soluble salts, the bichlorid is usually 
chosen. 

Cathartic. — Certain insoluble preparations of mercury — 
calomel, blue mass, mercury with chalk — have just enough 
irritant action on the bowel to induce catharsis. They are not 



HYDRARG YR UM. 325 

suitable remedies for habitual constipation, but on account of 
their thorough and agreeable action they are well adapted for 
unloading the bowel in dyspeptic diarrhea and in the begin- 
ning of acute infectious diseases. 

Diuretic. — Mercury in the form of calomel or blue mass is 
an active diuretic, and one that is well suited for carrying off 
dropsical effusions resulting from cardiac or hepatic disease. 

Absorbent. — Ointments of mercury are very efficacious in 
promoting the absorption of the exudation thrown out in cer- 
tain subacute and chronic inflammations. They are exten- 
sively employed for this purpose in synovitis, thecitis, arthritis, 
adenitis, and orchitis. It need scarcely be said that they are 
of no value in purulent inflammation. 

Administration. — Mercurial preparations may be given 
by the mouth, by inunction, by subcutaneous injection, or by 
fumigation. 

By the Mouth. — This is usually the best method of admin- 
istration when mercury is employed for its constitutional 
effects. Blue mass, mercury with chalk, mercurous chlorid 
(calomel), mercuric chlorid (corrosive sublimate), mercurous 
iodid, and mercuric iodid, are the compounds most frequently 
chosen for exhibition by the mouth. The insoluble prepara- 
tions are generally prescribed in pills or tablets. Corrosive 
sublimate may be given in solution or in pills or tablets. The 
biniodid is soluble in a solution of potassium iodid. 

By Inunction. — This method of administering mercury is 
useful when the stomach is irritable or when it is deemed 
desirable to hasten mercurialization. The method has disad- 
vantages in being uncleanly, troublesome, and uncertain as to 
dosage. About 1 dr. (4.0 gm.) of blue ointment may be 
rubbed into the groins, axillae, or inner surface of the thighs 
and arms once a day. In order to avoid local irritation a 
different region should be selected each day. For infants an 
ointment may be used consisting of I part of mercurial oint- 
ment and from 6 to 8 parts of lard. A piece of this the size 
of a hickory-nut may be spread every day upon a flannel 
binder which is worn around the abdomen. 

By Subcutaneous Injection. — Mercury may be given hypo- 
dermically in syphilis when a very rapid impression is neces- 
sary, or when other modes of administration have proved un- 
successful. This method is not suitable for ordinary cases. 
The injections are painful and are not unattended with danger. 
Local complications — induration, abscess, sloughing — are lia- 
ble to occur, and grave ptyalism may develop, especially in 
patients with chronic nephritis. Soluble preparations only 
should be employed. Insoluble preparations may accumu- 



326 ALTERA TIVES. 

late in the tissues for a time, and later give rise to severe 
constitutional symptoms. The best salts for hypodermic 
use are the bichlorid and succinimid. From 20 to 30 daily 
injections should be made deep into the back or buttock. 
The initial dose of the bichlorid should not exceed \ gr. 
(0.008 gm.), and this amount should be gradually increased 
to a maximum of \ gr. (0.016 gm.). The injections should be 
given through a platino-iridium needle which has been pre- 
viously sterilized. 

By Fumigation. — This method is sometimes employed in 
syphilis instead of inunction, when the stomach is intolerant. 
It is especially useful when the cutaneous lesions prove obsti- 
nate. The mercurial salt, preferably calomel, of which about 
20 gr. (1.3 gm.) are used, may be volatilized from a tin plate 
suspended over a spirit-lamp. The latter is placed under a 
stool or cane-seated chair, upon which is seated the patient, 
disrobed and surrounded by a blanket fastened to the neck. 
In about fifteen or twenty minutes the calomel is volatilized 
and deposited on the skin as a fine dust. The baths should 
be given just before retiring, and the sublimated mercury should 
be allowed to remain on the skin until the next morning. 
The treatment may be continued until slight tenderness of the 
gums develops. 

Blue Mass (Massa Hydrargyri, U. S. P.). — This is a tritu- 
rate of metallic mercury with honey of rose, glycerin, licorice, 
and althaea, containing 33 per cent, of the metal. The dose is 
from \-\o gr. (0.03-0.6 gm.). It is employed as a cathartic 
and diuretic. In the condition known as "biliousness" no 
treatment is so successful as the administration of a blue pill 
(5 g r - — °-3 g m -)> followed in the morning by Epsom salts or a 
Seidlitz powder. In the beginning of acute febrile diseases and 
dyspeptic diarrhea blue mass is an excellent cathartic for un- 
loading the bowel without inducing irritation. In combina- 
tion with powdered digitalis and squill it is an efficient diu- 
retic in the dropsy of chronic heart and liver disease. 

Mercury with Chalk (Hydrargyrum cum Creta, U. S. P.). 
— This is a light-gray, damp powder, without odor, and of a 
sweetish taste. It contains 38 per cent, of mercury intimately 
mixed with chalk, honey, and water. The dose is from ^-10 
gr. (0.03-0.6 gm.). It is used in the same class of cases as 
blue mass. It is particularly serviceable in the diarrhea of 
childre7i when the tongue is heavily coated, the breath fetid, 
and the stools are greenish or clay-colored. Hutchinson 
highly recommends mercury with chalk, in doses of from 
1-4 gr. (0.065-0.26 gm.), thrice daily, as a convenient and 
efficient form in which to administer mercury in syphilis. In 



HYDRARGYRUM. $2? 

congenital syphilis from J-to I gr. (0.016-0.065 gm.) may be 
given three times a day. 

Ointments of Mercury. — The U. S. Pharmacopoeia of 
1900 recognizes two ointments : Mercurial ointment (Unguen- 
tum Hydrargyri) and blue ointment {Unguentum Hydrargyri 
Dilutum). Mercurial ointment contains 50 per cent, of metallic 
mercury and 2 per cent, of oleate of mercury, 25 per cent, of 
lard, and 23 per cent, of suet. Blue ointment contains 6j per 
cent, of mercurial ointment (33 per cent, of metallic mercury) 
and 33 per cent, of petrolatum. These preparations are em^ 
ployed as antisyphilitics, absorbents, and parasiticides. In 
syphilis they are administered by inunction. In synovitis, bur- 
sitis, rheumatic arthritis, glandular enlargements, and syphilitic 
nodes they are valuable as absorbents. When the swelling is 
painful, an equal amount of belladonna ointment may be added 
for its sedative effect. In subacute rheumatism the local appli- 
cation to the affected joints of an ointment containing mercury 
and salicylic acid is often efficacious. 

U Acidi salicylici, gr. xxx (2.0 gm.) ; 

Olei terebinthinse, f^iiss (10.0 c.c.) ; 

Adipis lanae hydrosi, Sss (15.0 gm.) ; 

Unguenti hydrargyri, gj (30.0 gm.). M. 

Sig. Apply with gentle friction night and morning. 

In pediculosis pubis the parasites are quickly destroyed by 
rubbing into the affected parts a small amount of blue oint- 
ment. 

Mercurial Plaster (Emplastrum Hydrargyri, U. S. P.). — 
This is a plaster containing 30 per cent, of metallic mercury, 1 
per cent, of oleate of mercury, 10 per cent, of hydrous wool-fat, 
and 59 per cent, of lead-plaster. It is employed as an absorb- 
ent in chronic inflammatory swellings, glandular enlargements, 
syphilitic nodes, etc., but is far less efficient than the ointment. 

HYDRARGYRI CHLORIDUM CORROSIVUM, U. S. P. 

(Mercuric Chlorid; Corrosive Sublimate ; Bichlorid of Mercury ; HgCl 2 .) 

Mercuric chlorid appears in the form of colorless, odorless 
crystals, having an acrid, metallic taste. It is soluble in 13 
parts of water and in 3 parts of alcohol. The dose is from 
rk-TJ g r - (0.0006-0.005 gm.). 

Therapeutics. — Corrosive sublimate is employed chiefly 
as a germicide, an antisyphilitic, and a tonic. 

Germicide. — It is an energetic germicide, capable of destroy- 
ing most bacteria even in solutions of 1 : 20,000, and their 
spores in solutions of 1 : 10,000. Some micro-organisms, how- 
ever, like the bacillus of anthrax, are much less susceptible to 



328 ALTERATIVES. 

its action. In the presence of hydrogen sulphid it is con- 
verted into an insoluble and inert sulphid of mercury ; with 
albuminous matter it forms an impermeable albuminate, which 
prevents its further penetration ; it has a corroding action on 
metal; it is irritating to the tissues, and when applied too 
freely to wounds or mucous membranes, it may be absorbed 
in sufficient quantity to induce poisoning. Notwithstanding 
these drawbacks, most surgeons accord corrosive sublimate 
the first rank among germicides for use upon the skin of the 
patient and the hands of the operator, and for irrigating in- 
fected wounds and cavities. On account of its irritant proper- 
ties it should not be used on serous membranes. For the 
patient's skin and surgeon's hands a solution of from I : iooo 
to I : 500 should be employed ; for large wounds and cavities, 
1 : 10,000 to 1 : 5000; for small wounds, 1 : 2000; for irrigating 
the bladder and vagina, 1 : 20,000 to 1 15000; for irrigating 
the urethra, 1 : 40,000 to 1 : 20,000 ; and for irrigating the 
conjunctiva, 1 : 5000. Tartaric or citric acid may be advan- 
tageously combined with bichlorid solutions to prevent the 
mercuric salt from forming an insoluble albuminate with the 
albuminous matter of the tissues. Compressed tablets, each 
containing j\ gr. (0.48 gm.) of the salt with tartaric acid, are 
in common use. One of these added to a pint of water makes 
a solution of 1 : 1000. Ordinary water, on account of the lime 
which it contains, partially precipitates corrosive sublimate in 
the form of an oxid of mercury. This precipitation, however, 
can be prevented by adding common salt to the water. Bi- 
chlorid solutions cannot be used for sterilizing metal instru- 
ments. As a household disinfectant mercuric chlorid has 
several disadvantages. It is very poisonous ; it has a corrod- 
ing action on metals ; it becomes ineffective by contact with 
albuminous matters ; and it renders indelible any stains of 
feces or blood that may be on clothing. Solutions of from 
1 : 5000 to I : 1000, however, are serviceable for scrubbing 
floors, wood-work, and bare walls. It is not a suitable disin- 
fectant for sputum, feces, or other albuminous matters. 

As a parasiticide, corrosive sublimate is a useful remedy in 
pediculosis pubis and ringworm. In these affections it may be 
employed in the form of a lotion in the strength of from 2—4 
gr. (0.13-0.26 gm.) to the ounce (30.0 c.c.) of water, or, better, 
tincture of benzoin. 

The following solution, recommended by Jacobi, may be 
used as a local remedy in diphtheria : 

R Hydrargyri chloridi corrosivi, gr. i\ (0.08 gm.) ; 

Sodii chloridi, gr. xl (2.6 gm.) ; 

Aquae, Oj (0.5 L.). M. 



HYDRAR G YR UM. 3 29 

In nasal diphtheria this solution should be warmed and 
poured into the nares or from a nasal cup several times a 
day. 

Before the introduction of antitoxin, mercury, in the form 
of calomel or of corrosive sublimate, was extensively used 
internally in the treatment of diphtheria. It seems to have 
some value in this affection, but the manner of its action is 
unknown. Children bear the drug remarkably well, and ■£§ gr. 
(0.0015 gm.) of corrosive sublimate, gradually increased to -^5- gr. 
(0.003 g m -)> ma y be given every three or four hours to a child 
of five years. 

Compresses wrung out of bichlorid solutions (1 : 5000) are 
useful in erysipelas and in small-pox. 

Antisyphilitic. — Corrosive sublimate, though somewhat 
more irritant than the protiodid, is a reliable salt of mercury 
for use in syphilis. It may be administered either in pill or in 
solution. One-twentieth of a grain (0.003 g m -)> gradually in- 
creased to y 1 ^ gr. (0.005 g m -)> ma y b e gi yen three times a 
day after meals. The addition of a small amount of opium 
will usually serve to allay any gastric or intestinal irritation. 
In the late secondary period the bichlorid may be prescribed 
with potassium iodid, as in the following formula : 

R Hydrargyri chloridi corrosivi, gr. iss-ij (0.1-0.13 gm.) ; 
Potassii iodidi, ?>i v - v j ( I 5-°- 2 3-° gP 1 -) » 

Syrupi sarsaparillae compositi, f^iss (45.0 c.c); 
Aquae, q. s. ad f 3HJ (90.O c.c). M. 

Sig. A teaspoonful in water after meals. 

Corrosive sublimate is one of the best salts of mercury for 
hypodermic use. Sodium chlorid should be added to the 
solution to prevent the formation in the tissues of an insoluble 
albuminate. 

R Hydrargyri chloridi corrosivi, gr. vj (0.4 gm.) ; 

Sodii chloridi, gr. xl (2.6 gm.) ; 

Aquas destillatse, f§j (30.0 c.c). M. 

Sig. Inject 5-20 min. (0.3-1.2 c.c.) daily. 

Tonic. — Mercuric chlorid, in doses of 1 ^ 6 - ^ gr. (0.0006- 
O.OO I gm.), is sometimes useful as an adjuvant to iron in sec- 
ondary anemia. 

Incompatibles. — Corrosive sublimate has a wide range of 
incompatibilities. The most common substances precipitated 
by it are tannic acid, alkaline carbonates, albumin, iodids, 
silver nitrate, and solutions of lime. With potassium iodid it 
forms mercuric iodid, but if the potassium salt is present in 
excess, a colorless solution of the double iodid of mercury and 



330 ALTERA TIVES. 

potassium at once results, so that a combination of the two 
drugs is perfectly admissible. 

Yellow wash (lotio flava) is made by adding 24 gr. 
(1.6 gm.) of mercuric chlorid to 16 ounces (474.0 c.c.) of lime- 
water. Yellow mercuric oxid is precipitated and calcium 
chlorid remains in solution. It is sometimes employed as a 
stimulating dressing in the treatment of phagedenic venereal 
sores. 

HYDRARGYRI CHLORIDUM MITE, U. S. P. 

(Mild Mercurous Chlorid ; Calomel ; HgCl.) 

Calomel is a white, odorless, tasteless powder, insoluble in 
all ordinary menstrua. The dose is from -rV" 10 S r - (0.0065- 
O.65 gm.). 

Preparation. Dose. 

Pilulae Catharticae Composite, U. S. P. (contains I gr. 

— 0.06 gm.) 1-3 pills. 

Therapeutics. — Calomel is used internally as a cathartic 
(see p. 209), as a diuretic (see p. 232), as an antiphlogistic, and 
as an antisyphilitic. Externally it is employed as a stimulant, 
desiccant, and antiseptic. 

External Use. — Zinc ointment to which calomel (5-15 gr. 
to the ounce — 0.4-1.0 gm.) has been added makes an excel- 
lent application in subacute and chronic eczema. A dusting- 
powder composed of equal parts of calomel and zinc oxid is 
effective in venereal warts. Calomel is also efficacious in cor- 
neal idcers and phlyctenular conjunctivitis when there is not 
much ciliary irritation. It should be flicked into the eye by 
gently tapping a cameFs-hair brush loaded with the powder. 

Antiphlogistic. — Some practitioners believe that calomel is 
of service in limiting fibrinous exudation in inflammatory dis- 
eases of the serous membranes. For this purpose it has been 
much used in pleurisy, meningitis, iritis, and pericarditis, but 
its beneficial effects are very doubtful. 

Antisyphilitic. — Calomel has been used internally to com- 
bat syphilis, but the protiodid and the bichlorid are deci- 
dedly preferable, since they do not induce salivation so 
quickly. It is a suitable preparation, however, for volatiliza- 
tion when the patient is to be treated by fumigation. Some 
surgeons have recommended deep injections of oily mixtures 
of calomel in syphilis, but grave symptoms have occasionally 
resulted from its use in this way. 

Incompatibles. — Calomel is incompatible with hydro- 



HYDRARG YR UM. 3 3 1 

chloric acid, chlorates, chlorids, iodids, bromids, and lime- 
water. With hydrocyanic acid and potassium cyanid it forms 
the highly poisonous bicyanid of mercury. Mixtures of calo- 
mel and iodoform turn red from the formation of mercuric 
iodid. 

Black wash (lotio nigra) is made by adding 1 dr. (4.0 
gm.) of calomel to 1 pint (0.5 L.) of lime-water. Black mer- 
curous oxid is precipitated and calcium chlorid remains in 
solution. It is sometimes employed as a stimulating applica- 
tion in venereal sores. It is often very useful in rhus poisoning 
and acute eczema, when dabbed on the parts, allowed to dry, 
and followed by an application of zinc ointment. 

HYDRARGYRI IODIDUM RUBRUM, U. S. P. 

(Red Mercuric Iodid ; Biniodid of Mercury ; Hgl 2 .) 

Red iodid of mercury is a bright-red, amorphous powder, 
free from odor and taste. It is almost insoluble in water, 
soluble in 116 parts of alcohol, and freely soluble in solutions 
of potassium iodid. The dose is from -fa-lfe S r - (0-0012-0.005 
gm.). 

Preparation. Dose. 

Liquor Arseni et Hydrargyri Iodidi, U. S. P. 
(Donovan's solution : I per cent, of each 
iodid) 1-5 min. (0.06-0.3 c.c). 

Therapeutics. — In its effect and strength the biniodid of 
mercury resembles the bichlorid. In the late secondary stage 
of syphilis it is often of value when given in a solution of potas- 
sium iodid, as in the following formula : 

R Hydrargyri iodidi rubri, gr. j (0.065 g m -) '■> 

Potassii iodidi, ,^ij-i v (8.0-15.0 gm.) ; 

Aquae, f^ij (60.0 c.c.) ; 

Syrupi sarsaparillae compositi, q. s. ad f^iv (120.0 c.c). M. 

Sig. A dessertspoonful in water after meals. 

Donovan's solution is used internally as an alterative in 
chronic rheumatism, tuberculous adenitis, and tertiary syphilis. 

HYDRARGYRI IODIDUM FLAVUM, U. S. P. 

(Yellow Mercurous Iodid ; Protiodid of Mercury ; Green Iodid of Mercury ; 

HgL) 

Protiodid of mercury is a yellow, amorphous, insoluble pow- 
der, free from odor and taste. The dose is from T V~ 2 S r - 
(0.006-0.03 gm.). 

Therapeutics. — The protiodid of mercury is far less irri- 
tant than the biniodid. Ordinarily, it is the best preparation 



3 3 2 AL TERA TI VES. 

for use in syphilis. It should be given in pills to which a little 
opium may be added if it excite colic or diarrhea. 

HYDRARGYRI NITRAS. 

(Mercuric Nitrate ; Hg(N0 3 ) 2 .) 

Mercuric nitrate is official in two forms : 

Liquor Hydrargyri Nitratis, U. S. P. (contains 60 per cent, of mercuric 

nitrate and 11 per cent, of free nitric acid). 
Unguentum Hydrargyri Nitratis, U. S. P. (citrine ointment : contains 7 

per cent, of mercuric nitrate). 

Therapeutics. — The solution of mercuric nitrate is a pow- 
erful caustic. It is extensively employed for the cauterization 
of mucous patches and sloughing venereal sores. The danger 
of inducing salivation from using it too freely must be borne 
in mind. Citrine ointment, more or less diluted, may be used 
as a stimulant application in indolent ulcers and chronic eczema. 
Diluted with 8 parts of petrolatum it makes an efficient appli- 
cation for granulating venereal ulcers. 

HYDRARGYRUM AMMONIATUM, U. S. P. 

(Ammoniated Mercury; Mercuric Ammonium Chlorid; White Precipitate; 

NH 2 HgCl.) 

Ammoniated mercury is made by the action of ammonia on 
corrosive sublimate, and appears as a white, insoluble powder, 
free from odor and taste. 

Preparation. 
Unguentum Hydrargyri Ammoniati. U. S. P. (10 per cent.). 

Therapeutics. — Ammoniated mercury is employed exter- 
nally, in the form of the ointment, as a stimulant and as a 
parasiticide. It is often serviceable in chronic eczema, psoriasis, 
and ringworm. The official ointment, however, is too strong 
for ordinary use, a strength of from 20-30 gr. (1.3-2.0 gm.) to 
the ounce (30.0 gm.) being quite sufficient. 

HYDRARGYRI CYANIDUM. 

(Mercuric Cyanid ; Hg(CN) 2 .) 

Mercuric cyanid occurs in the form of colorless, prismatic 
crystals, odorless, and of a bitter, metallic taste. It is freely 
soluble in water and alcohol. The dose is from ? V~ru" S r - 
(0.0016-0.006 gm.). 

Its action, though less irritant, resembles that of the bi- 
chlorid. It has been used as a substitute for the latter in sur- 
gical practice and also in the hypodermic treatment of syphilis. 



HYDRAR G YR UM. 333 

HYDRARGYRI OXIDUM. 

(Mercuric Oxid; HgO.) 

Mercuric oxid occurs in two forms : Yellow oxid {Hy- 
drargyri Oxidum Flavum, U. S. P.) and red oxid (Hydrargyri 
Oxidum Rubrum, U. S. P.). Both are heavy, permanent, in- 
soluble powders, odorless, and of a somewhat metallic taste. 
The yellow oxid is an impalpable powder ; the red oxid is more 
or less crystalline. They are not used internally. 

Preparations. 
Unguentum Hydrargyri Oxidi Flavi, U. S. P. (10 per cent.). 
Unguentum Hydrargyri Oxidi Rubri, U. S. P. (10 per cent.). 
Oleatum Hydrargyri, U. S. P. (25 per cent, of yellow oxid). 

Therapeutics. — The oxids of mercury are used externally 
for their stimulant and alterative effects. In certain chronic in- 
flammatory diseases of the eye — phlyctenular conjunctivitis, 
keratitis, and blepharitis marginalis, an ointment of the yellow 
oxid is often very useful. In the last affection it is particularly 
efficacious when applied at night to the margins of the lids in 
the strength of 1 gr. of the oxid (0.06 gm.) to 1 dr. (4.0 gm.) 
of vaselin. In chronic eczema an ointment containing from 
10-20 gr. (0.6-1.3 gm.) to the ounce (30.0 gm.) is sometimes 
serviceable. In the form of a dusting-powder the oxids of 
mercury have also been used in chancroidal and syphilitic 
sores. In chronic adenitis and other indolent inflammatory in- 
durations one of the official ointments or the oleate may be 
employed for its sorbefacient effect. 

The red oxid may be used in the same class of cases as the 
yellow oxid, but it is less satisfactory on account of its crys- 
talline character. 

HYDRARGYRI SUBSULPHAS FLAVUS. 

(Yellow Mercuric Sulphate ; Turpeth Mineral; Hg(HgO) 2 S0 4 .) 

Yellow mercuric sulphate is a lemon-yellow, odorless, and 
tasteless powder, sparingly soluble in water. The dose is from 
2-3 gr. (0.1-0.2 gm.), repeated once. 

Therapeutics. — This preparation of mercury was formerly 
much used as an emetic in croup, but it has been largely re- 
placed by less poisonous and less irritant drugs. 

HYDRARGYRI SALICYLAS. 

(Basic Mercuric wSalicylate, HgC 7 H 4 3 .) 

Mercuric salicylate is a white amorphous powder, without 
odor or taste. It is insoluble in water or alcohol, but readily 
so in water containing sodium chlorid. It has been especially 



334 AL TERA TIVES. 

recommended for intramuscular administration in syphilis, liquid 
paraffin or almond oil (i in 10) being used as a vehicle. The 
dose is from |to I gr. (0.02-0.065 gm.). 

R Hydrargyri salicylates, gr. xv (i.o ex.); 

Petrolati liquidi, f^iiss (10.0 ex. ). M. 

Sig. From 3-10 min. (0.12-0.6 ex.), intramuscularly, once a week 
or every ten days. 

HYDRARGYRI SUCCINIMIDUM. 

(Mercuric Succinimid, HgC 8 H g 4 N 2 .) 

Mercuric succinimid is a white crystalline powder, soluble in 
75 parts of cold water and in 300 parts of alcohol. It is com- 
paratively non-irritant and does not precipitate albumin. The 
dose, by the mouth, is from \-\ gr. (0.0 1 -0.0 15 gm.). 

Mercuric succinimid has been used chiefly by hypodermic 
injection in the treatment of syphilis, from 8-15 minims (0.5-1.0 
c.c.) of a 2.5 per cent, solution being given daily or every other 
day. Recently it has been highly recommended by B. L. 
Wright in pulmonary tuberculosis, injections being given every 
other day (£ gr.-0.013 gm.) for two months and followed by a 
course (two weeks) of potassium iodid. 

ICHTHYOL. 

(Ammonium Sulpho-ichthyolate.) 

Ichthyol is the ammonium salt of ichthyol sulphonic acid. 
The latter is the product of the action of sulphuric acid on an 
oily substance obtained by the destructive distillation of a 
bituminous mineral rich in fossil fish, found in the Tyrol. It 
is a thick, reddish-brown liquid, having a bituminous odor and 
taste. It is soluble in water and in a mixture of alcohol and 
ether, miscible with oils and glycerin in all proportions, and 
almost insoluble in strong alcohol or ether. It contains nearly 
15 per cent, of sulphur, and to this ingredient its therapeutic 
properties, no doubt, are largely due. The dose is from 2-10 
gr. (0.13-0.65 gm.), in capsules or pills. 

Physiologic Action. — When applied to the skin in con- 
centrated form, ichthyol produces slight redness and burning. 
Its absorption through the unbroken skin is readily effected 
if gentle friction be used in the application. The efficacy of 
the drug in many inflammatory diseases of the skin and mu- 
cous membranes has been attributed to a constricting action 
on the vessels and to an alterative influence on the deeper 
tissues, especially the glandular cells. Fessler, Abel, Neisser, 
and others have shown, also, that it possesses decided bacter- 
icidal properties. According to Neisser, even in solutions so 



ICHTHYOL. 335 

dilute as I per cent, it is rapidly destructive to gonococci. In- 
ternally, large doses cause eructations, nausea, vomiting, and 
diarrhea. 

Therapeutics. — Ichthyol is very largely employed exter- 
nally as an antiseptic and alterative. In the form of an oint- 
ment it is decidedly useful in reducing inflammatory swelling 
in glands and joints. The best vehicle is lanolin, and the 
strength of the application may vary from 25 to 50 per cent. 
It is of some value as a local remedy in erysipelas, and in this 
disease it may be combined with blue ointment, as in the fol- 
lowing formula, so highly extolled by Roswell Park : 

R Ichthyol, gr. xxx-xl (2.0-2.6 gm.) ; 

Resorcinolis, ^ss (2.0 gm.) ; 

Unguenti hydrargyri, £iv (15.5 gm.) ; 

Adipis lanae hydrosi, gv (20.0 gm.). — M. 

It is said to be useful, either as a lotion or an ointment (10 to 
20 per cent), in certain diseases of the skin, especially acne, vesic- 
ular and sqjiamous eczema, pruritus, and urticaria. It is some- 
times of service in bruises, sprai?is, and chilblains. Tampons 
saturated with ichthyol and glycerin (1 to 20 or 1 to 10) are 
sometimes remarkably beneficial in oophoritis, perimetritis, en- 
dometritis, cervical catarrh, and go?iorrheal vaginitis. In atro- 
phic rhinitis no remedy is so efficacious as ichthyol in relieving 
the disagreeable symptoms. After the nares have been thor- 
oughly cleansed, pledgets of cotton soaked in an aqueous 
solution (20 to 50 per cent.) should be inserted and allowed 
to remain for a period of from fifteen to twenty minutes, or in 
bad cases the drug may be applied pure by means of a probe 
armed with cotton. 

The chief drawback to the use of ichthyol externally is its 
unpleasant, bituminous odor ; this can be disguised in a meas- 
ure by the addition of oil of bergamot (1 140). 

Ichthyol has been used internally in a variety of diseases, 
particularly tuberculosis and rheumatism, but the testimony to 
its efficacy is not convincing. 

Incompatibles. — Acids, alkalis, and alkaloidal salts. 

Ichthalbin. — This preparation is a combination of ich- 
thyol and albumin, appearing as a brownish powder, odorless, 
and nearly tasteless. The dose is from 5—10 gr. (0.33-0.65 
gm.). It has been thoroughly exploited as a substitute for 
ichthyol, both for internal and external use. 

Icnthoform is a condensation product of ichthyol and 
formaldehyd. It has been recommended as a substitute for 
iodoform ; but notwithstanding its freedom from odor it is less 
satisfactory than the older remedy. 

Ichthargan is a compound of ichthyol and silver, contain- 



3 3^ AL TERA TIVES. 

ing 30 per cent, of metallic silver in organic chemical combi- 
nation. It is a brown, amorphous powder, with a faint odor 
of chocolate. It is freely soluble in water, diluted alcohol, 
and glycerin. It has been used with asserted good results in 
gonorrhea, injections of a 1 : 10,000 to a 1 : 1000 solution 
being made three or four times daily. 

Thiol. — This is a synthetic product obtained by the action 
of sulphur and sulphuric acid upon hydrocarbon as formed by 
the destructive distillation of peat. It was introduced as a 
substitute for ichthyol, but it has not proved a very formida- 
ble rival. 

AURI ET SODII CHLORIDUM, U. S. P. 

(Gold and Sodium Chlorid; AuCl 3 + NaCl.) 
The gold and sodium chlorid of the Pharmacopeia is a mix- 
ture of equal parts, by weight, of dry gold chlorid and sodium 
chlorid. It is an orange-yellow powder, slightly deliquescent, 
of a saline and metallic taste. It is freely soluble in water. 
The dose is from 2 1 o" , l g r - (0.003-0.016 gm.), in pill. 

Physiologic Action and Therapeutics. — Gold and 
sodium chlorid is supposed to act as an alterative and a tonic. 
Large doses have an irritant action and excite gastro-enteritis. 
It has been recommended in a number of diseases, especially 
in diabetes, hysteria, neurasthenia, tertiary syphilis, chronic alco- 
holism, and sclerosis of the spinal cord, but it is of very doubt- 
ful value. 

COLCHICUM. 

(Meadow Saffron.) 

Colchicum is the corm and seed of Colchicum autumnale, a 
bulbous perennial growing in Southern Europe and Northern 
Africa. The corm is official as Colchici cormus, and the seed as 
Colchici semen. The active principle of the drug is the alka- 
loid, colchicin (Colchicina, U. S. P.), which is a whitish, amor- 
phous or crystalline powder, of a saffron odor and bitter taste, 
and is readily soluble in water and alcohol. The dose of 
colchicin is from 1 | - 3 1 gr. (0.0004-0.002 gm.). 

Preparations. Dose. 

Extractum Colchici Cormi, U. S. P £-2 gr. (0.03-0.13 gm. ). 

Fluidextractum Colchici Seminis, U. S. P. . . 2-5 min. (0.1-0.3 c.c. ). 

Tinctura Colchici Seminis, U. S. P 10-30 min. (0.6-2.0 c.c). 

Vinum Colchici Seminis, U. S. P 10-30 min. (0.6-2.0 c.c). 

Physiologic Action. — In warm-blooded animals large 
doses of colchicum or of its alkaloid excite severe abdominal 
pains, nausea, vomiting, and diarrhea. The discharges are at 
first serous, but later they may become mucous and even 



colchicum. 337 

bloody. These symptoms are followed by progressive motor 
paralysis, enfeeblement of the circulation, collapse, and finally 
by death from asphyxia. 

Postmortem examination usually reveals pronounced in- 
flammatory lesions in the alimentary canal. In some instances, 
however, no morbid changes have been observed. Fatal poi- 
soning has occurred from the ingestion of less than 3 dr. (11.0 
c.c.) of the wine of the root (U. S. P. 1890), and of less than 
\ gr. (0.03 gm.) of colchicin. 

The gastro-intestinal features of the poisoning are probably 
due to the direct irritant action of the drug, although Jacobj 
attributes them to increased irritability of the motor nerves of 
the bowel, in consequence of which the muscular coat responds 
too vigorously to the ordinary stimuli. The paralysis, accord- 
ing to Rossbach, results from depression of the central ner- 
vous system. Upon the circulation colchicum appears to have 
no direct influence. Both the water and the solids of the urine 
are somewhat increased after moderate doses of the drug, but 
large doses may be followed by suppression. 

Treatment of Poisoning. — The stomach should be evac- 
uated as speedily as possible. Albumin and other demulcents 
are useful in allaying irritation and in preventing further in- 
jury to the mucous membrane. Tannic acid is of no value as 
an antidote. Morphin may be given hypodermically to re- 
lieve pain and to inhibit peristalsis. The usual measures will 
be required to combat the collapse. 

Therapeutics. — The only disease in which colchicum is 
of value is gout. The good and bad effects of the drug in 
chronic joint affections seem to have been known as early as 
the sixth century of the Christian era. For many years it was 
neglected by regular practitioners, although it still served as 
the basis of many celebrated nostrums. Later the studies of 
Halford, Watson, and Garrod reestablished it in the confidence 
of the profession. The way in which gouty inflammation is 
affected by colchicum is not understood, and cannot be, until 
our knowledge of the pathology of the disease becomes more 
complete. The drug is most potent in acute gout, the pain 
and swelling of which it relieves as if by magic ; it is less effi- 
cacious in the chronic manifestations of the disease. In the 
different forms of rheumatism it is useless. 

Administration. — As colchicum is powerful for harm as 
well as for good, considerable care should be exercised in its 
administration. Only small doses should be employed, and 
these should be withdrawn or considerably reduced so soon 
as the pain has been relieved. Large doses, even if they do 
22 



338 AL TERA TIVES. 

not excite irritation of the stomach or purging, may, by sup- 
pressing the local manifestations too abruptly, cause the grave 
visceral disturbances to which the term retrocedent gout has 
been applied. The wine and the tincture are reliable prepara- 
tions ; they should be taken, well diluted, after food. Alkalis 
are useful adjuvants, and may be combined with the colchicum, 
as in the following formula : 

R Potassii bicarbonatis, ^ij (8.0 gm.) ; 

Vini colchici seminis, fgiiss (10.0 c.c.) ; 

Aqua menthas piperitse, q. s. ad f ^iv (120.0 c.c). — M. 
Sig. A tablespoonful in a wineglassful of water thrice daily, after 
meals. 

Colchicin is a convenient form for administering in pills or 
capsules. 

GUAIACUM, U. S. P. 

(Guaiac.) 

Guaiac is the resin of Guaiacum officinale (Lignum Vitae), a 
large tree growing in the West Indies and South America. It 
appears as irregular masses, of a reddish-brown color, turning 
greenish-brown on exposure, and has an aromatic odor and 
an acrid taste. It is soluble in alcohol and in alkaline fluids, 
but is insoluble in water. Alcoholic solutions turn blue on 
the addition of oxidizing agents. It contains several resinous 
acids and aromatic oils and gums. The dose is from 5-30 gr. 
(0.3-2.0 gm.). 

Preparations. Dose. 

Tinctura Guaiaci, U. S. P. (20 per cent, of 

the resin) \-\ fl. dr. (2.0-4.0 c.c). 

Tinctura Guaiaci Ammoniata, U. S. P. (20 

per cent, of the resin in aromatic spirit of 

ammonia) ^-1 fl. dr. (2.0-4.0 c.c). 

Therapeutics. — Guaiac possesses considerable power,, 
though less than colchicum, in relieving gouty inflammation. 
It is especially efficacious in the subacute and chronic forms 
of the disease. In acute gout it may be substituted advan- 
tageously for colchicum so soon as the pain has subsided. 
According to Garrod, when it is taken in the intervals of 
gouty attacks it is very effective in averting their recurrence. 
The drug is quite innocuous, and may be taken for indefinite 
periods without inducing untoward effects. It is also used in 
tonsillitis and chronic rheumatism. 

Administration. — The tinctures are reliable preparations, 
but as they have a very disagreeable taste, they should be 
given in the form of an emulsion. The resin itself may be 
given in cachets or in an emulsion. 



SARSAPARILLA— JAMBUL. 339 

R Guaiaci, ^iisss (io.o gm.) ; 

Acaciae, q. s. 

Syrupi, f^iv (15.0 c.c); 

Aquae cinnamomi, q. s. ad f^iv (120.0 c.c). 

Misce et fiat emulsum. 
Sig. A dessertspoonful in water after meals. 

Incompatibles. — Mineral acids and spirit of nitrous ether. 
Water is incompatible with the tinctures. 

SARSAPARILLA, U. S. P. 

Sarsaparilla is the root oiSmilax medica and of other species 
of Smilax, large perennial climbers growing in swampy places 
in tropical America. It contains a volatile oil, resin, and sev- 
eral saponins. 

Preparations. Dose. 

Fluidextractum Sarsaparillse, U. S. P. . . . £-2 fl. dr. (2.0-8.0 c.c). 

Fluidextractum Sarsaparillas Compositum, 

U. S. P. (sarsaparilla, 75 parts ; glycyrrhiza, 

1 2 parts; sassafras, 10 parts; mezereum, 3 

parts; glycerin, 10 parts; diluted alcohol 

to make 100 parts) 5-2 fl. dr. (2.O-8.O C.C.). 

Syrupus Sarsaparillae Compositus, U. S. P. 
(fl. ext. sarsaparilla, 20 parts ; fl. ext. gly- 
cyrrhiza, 1.5 parts; fl. ext. senna, 1.5 
parts ; sugar, 65 parts ; oil of sassafras, oil 
of gaultheria, and oil of anise, of each, 0.02 
part ; water to make 100 parts) .... 1-4 fl. dr. (4.0-15.0 c.c). 

Therapeutics. — The action of sarsaparilla is very feeble. 
It has been used as an alterative in syphilis and tuberculosis, 
but it is without value. It is chiefly useful as a vehicle to 
disguise the taste of unpalatable drugs, particularly potassium 
iodid. 

JAMBUL. 

(Java Plum.) 

Jambul is the root and seeds of Eugenia jambolana, a large 
tree growing in the East Indies. The active constituent of 
the drug has not been determined. The seeds are more pow- 
erful than the root, and may be given powdered in doses of 
from 5-20 gr. (0.3-1.3 gm.), in capsules. 

Preparation. Dose. 

Fluidextractum Jambul 10-30 min. (0.6-2.0 c.c). 

Therapeutics. — Jambul has been used solely as a remedy 
in diabetes mellitus, for which it was originally recommended 
by Banatvala, of Madras. Binz found that it materially les- 
sened the excretion of sugar in phloridzin diabetes, but Min- 
kowski found it absolutely useless in experimental pancreatic 



340 AL TERA TIVES. 

diabetes. Clinically, we have derived some benefit from it in 
a few cases of a mild type. Large doses sometimes lessen the 
glycosuria, but increase the quantity of urine. Von Noor- 
den, in a study of 600 cases of diabetes, concludes that while 
jambul has no very marked action on the elimination of sugar, 
it is a good adjuvant to dietetic and hygienic procedures. 

MEZEREUM, U. S. P. 

(Mezereon.) 

Mezereum is the bark of Daphne Mezereum and of other 
species oi Daphne, small shrubs growing in mountainous dis- 
tricts in Europe and Asia. It contains a bitter glucosid and 
an irritant volatile oil. 

Preparations. 
Fluidextractum Mezerei, U. S. P. 

Fluidextractum Sarsaparillge Compositum, U. S. P. (3 per cent, of 
mezereum). 

Therapeutics. — Mezereum is an active irritant, and when 
applied to the skin it causes vesication. Large doses of the 
fluid extract taken internally produce severe abdominal pain, 
followed by vomiting and purging. It has been recommended 
as an alterative in chronic rheumatism, syphilis, and various skin 
diseases, but its utility has never been satisfactorily demon- 
strated. Except in the form of the compound, fluid extract of 
sarsaparilla is never prescribed internally. Externally the 
fluid extract has been used as an irritant application for indo- 
le tit ulcers. 

CALX SULPHURATA, U. S. P. 

(Sulphurated Lime; Crude Calcium Sulphid.) 

Sulphurated lime is a mixture containing at least 60 per 
cent, of calcium monosulphid, together with calcium sulphate 
and varying proportions of carbon. It is a pale gray powder, 
having a nauseous, alkaline taste and a faint odor of hydrogen 
sulphid. It is slightly soluble in water and insoluble in alco- 
hol. On exposure to air it is gradually decomposed. The 
dose is from ^ \ gr. (0.006-0.03 gm.), in pills, capsules, or 
powders. 

Therapeutics. — As was first pointed out by Ringer, sul- 
phurated lime possesses some power of preventing and arrest- 
ing suppuration. It has been found especially useful in piistu- 
lar acne, boils, and carbuncles. In follicidar tonsillitis and in 
quinsy, doses of -^ gr. (0.003 gm.) every hour sometimes yield 
excellent results. It is better to give small doses at short in- 
tervals than large doses infrequently, since the latter are more 
prone to derange digestion and to cause disagreeable eructa- 



GLAND ULyE THYROIDEsE SICCM. 34 1 

tions of sulphureted hydrogen. As the drug deteriorates on 
keeping, only fresh preparations should be used. 

As a local remedy, in the form of Vleminckx's solution, it 
is often very efficacious in acne rosacea. 

R Cakis, ^ss (15.5 gm.) ; 

Sulphuris sublimati, ?j (31.1 gm.); 

Aquae, f^x (296.0 c.c). 

Coque ad f^vj (177.5 c.c), deinde filtra. 
Sig. Dilute with 10 parts of water and apply to the affected parte. 

URANII NITRAS. 

(Uranium Nitrate ; Uranyl Nitrate ; U0 2 (N0 3 ) 2 4- 6H 2 0.) 

Uranium nitrate occurs as light-yellow, rhombic prisms, 
soluble in water, alcohol, and ether. The dose is \ gr. (0.03 
gm.), gradually increased to 5 gr. (0.3 gm.) or more, freely 
diluted with water, after meals. 

Therapeutics. — In large doses uranium salts act as irri- 
tant poisons, producing gastro-enteritis and nephritis. More- 
over, they affect the oxyhemoglobin of the blood in such a 
way that its oxygenating power is much reduced. This action 
on the blood may be responsible for the glycosuria, which, 
according to Leconte, results from the prolonged use of 
uranium compounds. 

West, Morrison, Duncan, and others have observed im- 
provement in cases of diabetes mellitus from the use of uranium 
nitrate in doses of from 5-20 gr. (0.3-1.3 gm.) two or three 
times a day. In general, however, the drug has proved dis- 
appointing. It certainly has no specific influence on the dis- 
ease, and whatever action it may have in lessening the excre- 
tion of sugar probably depends, as Symonds suggests, on its 
effect in retarding the digestion of starches. 

GLANDULE THYROIDE^ SICCj®, U. S. P. 

(Desiccated Thyroid Glands ; Thyroid Extract. ) 

The profession is largely indebted to the observations of 
Kocher and to the experimental researches of Horsley for the 
treatment of myxedema and allied conditions by the adminis- 
tration of thyroid gland. Kocher found that complete removal 
of the thyroid gland was followed in many instances by the 
appearance of a peculiar cachexia, the symptoms of which 
were almost identical with those of myxedema. Horsley 
showed that thyroidectomy in monkeys induced a similar con- 
dition. Schiff proved that the bad effects of thyroidectomy 
in animals could be averted by transplanting the gland in the 
peritoneum or subcutaneous tissue, and thereupon Horsley 



342 ALTERATIVES. 

suggested this treatment for myxedematous conditions in 
man. Murray, in 1 891, found that transplantation of the 
gland was unnecessary, as the same results could be secured 
from hypodermic injections of thyroid juice, and a little later 
Mackenzie demonstrated that thyroid feeding was equally 
efficacious. 

According to Baumann, the active constituent of the thyroid 
gland is iodothyrin, a non-proteid compound containing from 
5 to 10 per cent, of iodin. This substance is localized in the 
colloid matter, and is probably secreted by the gland in asso- 
ciation with an iodin proteid, the two forming the thyreoglobu- 
lin of Oswald. 

Physiologic Action. — Large doses of thyroid extract 
frequently, but not invariably, produce a train of symptoms to 
which the term thyroidism has been applied. The most com- 
mon manifestations of this intoxication are restlessness, in- 
somnia, headache, palpitation of the heart, weakness of the 
circulation, anorexia, nausea, elevation of temperature, free 
perspiration, shortness of breath, tremors and twitchings of 
the limbs, prostration, and progressive loss of flesh. It will 
be observed that these symptoms are not unlike those of ex- 
ophthalmic goiter, and to make the resemblance more com- 
plete, swelling of the thyroid gland and exophthalmos have 
occurred in a few instances. Coppez has reported 5 cases of 
optic neuritis from the continued use of large doses. 

In man, the most constant effect of thyroid extract in medici- 
nal doses is increased oxidation, in consequence of which a 
considerable reduction in the body-weight occurs. Both the 
proteids and the fats suffer disintegration, but, according to 
Vendelstadt, only one-sixth of the loss of weight can be attrib- 
uted to the destruction of nitrogenous compounds, the rest 
being due to oxidation of fats and to increased excretion of 
water. The excessive catabolism of proteids is made evident 
by the increased excretion in the urine of nitrogen and of phos- 
phorus ; the more rapid comoustion of fats, by the increased 
elimination of carbon dioxid and the greater demand for 
oxygen. 

In excess, thyroid extract frequently increases the rate of 
the pulse and lowers the arterial pressure. The manner in 
which these effects on the circulation are produced is not 
known. The hurried respiration observed in thyroidism may 
be due to the increased demand for oxygen. Even in mod- 
erate doses the drug usually increases the quantity of urine, 
and in large doses it may induce albuminuria and glycosuria. 

Elimination. — Iodothyrin must be decomposed in the 
body, at least to some extent, since after its administration 
iodin appears in the urine. Hutchinson found this element 



GLANDULE THYROIDEJE SICC^. 343 

in the urine of a dog three hours after the administration of 
15 gr. (1 gm.) of colloid matter. That a part of the active 
constituent resists destruction in the body and escapes through 
avenues other than the kidneys is evidenced by the fact that 
an infant may acquire thyroidism through the mother's milk. 

Therapeutics. — The diseases in which thyroid extract is 
most efficacious are cretinism and myxedema of the adult. In 
cretinism the results are often truly remarkable, especially when 
the treatment is instituted early. " Within six weeks," as 
Osier writes, " a poor, feeble-minded, toad-like caricature of 
humanity may be restored to mental and bodily health." In 
both affections the remedy must be continued throughout life, 
otherwise relapses occur. After the symptoms have been re- 
lieved, a weekly or biweekly dose may be all that is necessary 
to maintain normal metabolism. Thyroid extract sometimes 
proves efficacious, also, in infantilism, and in certain other con- 
ditions on the borderland of myxedema, in which imperfect 
mental and physical development is a prominent feature. 

Considerable success has attended the use of the drug in 
simple goiter, especially in that form met with in adolescents. 
No effect, of course, can be expected from the treatment in 
the old cystic goiters of adults. In exophthalmic goiter thy- 
roid feeding is either useless or harmful. 

The loss of flesh following the administration of thyroid 
extract suggested its use in obesity. Ebstein believes that the 
treatment is not a rational one, since the drug causes a waste 
of the body-proteids as well as of the fats. The nitrogen loss 
can be controlled in a measure, however, by increasing the 
amount of proteids in the food, so that it does not become an 
insurmountable objection to the treatment. In some cases 
of obesity the remedy proves entirely satisfactory and is not 
followed by any unpleasant consequences. It is most effective 
in the cases which bear a certain resemblance to myxedema, 
in which the skin is pale and the tissues are soft and flabby. 
Unfortunately, many patients rapidly acquire a tolerance for 
the drug, and for this reason relapses are common. 

In certain skin diseases, such as psoriasis and ichthyosis, thy- 
roid extract is occasionally serviceable, but in the majority of 
cases it proves disappointing. In inoperable cancer it is often 
useful as a palliative remedy in relieving pain, dispelling dis- 
agreeable odor, and retarding ulceration. The drug seems 
to have a special influence on the uterus. There is consider- 
able testimony as to its efficacy in metrorrhagia from various 
causes, and some authorities go so far as to claim for it the 
power of reducing the size of uterine fibroids. Montgomery 
has found it useful in sterility dependent upon obesity. 



344 ALTERATIVES. 

The hope that thyroid extract might prove valuable in cer- 
tain forms of insanity has not been realized. While some 
observers, notably Mabon and Babcock and Easterbrook, have 
found it useful in acute melancholia, acute mania, puerperal 
and climacteric insanities, and stuporous states, the testimony 
of most alienists has been unfavorable. 

Administration. — As persons vary considerably in their 
susceptibility to thyroid preparations, it is always advisable to 
begin with small doses and gradually to increase them. As a 
rule, it is better to give small doses frequently than large 
doses at long intervals. Treatment should be suspended, at 
least temporarily, on the very first appearance of untoward 
symptoms. Mabille and Ewald have shown that the drug is 
much better received when combined with small doses of 
arsenic. Individuals with tuberculosis, Bright's disease, and 
cardiac insufficiency are generally intolerant to thyroid medi- 
cation. 

Thyroid gland may be given in the form of the fresh glands 
of the sheep, the dried glands (Glandulae Thyroideae Siccse), 
the glycerin extract (Liquor Thyroidei, B. P.), or iodothyrin. 
The fresh glands may be given raw or slightly cooked in doses 
of from \- \ of a gland a day. The dried glands and the 
glycerin extract, however, are far more convenient and are 
just as potent. Dry thyroid is a light, dull-brown powder, 
with a meat-like odor and taste. On exposure to air and 
moisture it is liable to decompose. The dose is from 1-5 gr. 
(0.06-0.3 gm.) three times a day. The glycerin extract is a 
pinkish turbid fluid, without putrescent odor. One hundred 
min. (6.0 c.c.) equal one fresh gland. The dose is from 5-15 
min. (0.3-1.0 c.c). Tablets of iodothyrin triturated with milk- 
sugar are on the market, and may be given in doses of from 
2-10 gr. (0.13-0.6 gm.) thrice daily. 

GLANDULA THYMUS. 

(Thymus Gland.) 

The persistence of the thymus in the majority of cases of 
exophthalmic goiter suggested the possibility of an antagonism 
between this gland and the thyroid. Reasoning from this pre- 
mise, many have employed thymus preparations in the treat- 
ment of Graves's disease. Kinnicutt, in 1897, collected 62 cases 
treated with the gland. Of these, 36 cases showed improve- 
ment; 25 were unimproved or showed aggravation of the 
symptoms. Of 20 cases treated by Mackenzie, 1 died, in 6 no 
improvement was observed, and in 1 3 there was some improve- 
ment. In none of the cases, however, was the effect so de- 



HYPOPHYSIS CEREBRI— TESTIS AND OVARIUM. 345 

cided as to justify the conclusion that the thymus has any 
great therapeutic activity. Mendel, Mettenheimer, and others 
claim to have had good results from the use of thymus prepa- 
rations in rickets. They base the treatment on Friedleben's 
observation that the thymus gland is often atrophied in rachitic 
children, and on Mendel's observation that removal of the 
thymus in dogs induces symptoms resembling rachitis. The 
dose of the dried gland is from 10-15 gr. (0.6-1.0 gm.) or 
more three or four times a day. 

HYPOPHYSIS CEREBRI. 

(Pituitary Body.) 

Schaefer and Vincent have demonstrated the existence of 
two substances in the infundibular part of the pituitary body, 
one producing a rise and the other a fall of blood-pressure. 
They distinguish them as the pressor and depressor substances 
respectively, the former being insoluble in alcohol and ether, 
while the latter is soluble in both of these fluids. The pressor 
substance, the more active of the two, when given hypoder- 
mically, stimulates the heart and constricts the arterioles, in 
consequence of which it raises the blood-pressure, slows the 
pulse, and increases the quantity of urine. 

The almost constant finding of lesions of the hypophysis in 
acromegaly suggested the use of pituitary extract in the treat- 
ment of this disease. Of 20 cases so treated collected by Hins- 
dale, 9 showed some improvement in the subjective symptoms. 
The dose of the dried extract is from 3-5 gr. (0.2-0.3 gm.) 
three times a day. 

TESTIS AND OVARIUM. 

In 1889 Brown-Sequard announced that he had personally 
experienced remarkable rejuvenating effects from injections of 
the extract of the testicle of rabbits. Emanating from such a 
high authority, this announcement led rapidly to the use of 
orchitic extracts, not only in senility, but in impotence, neuras- 
thenia, hysteria, locomotor ataxia, and many other affections 
of the nervous system. More or less favorable results of this 
treatment have been reported, but in no instance has the good 
achieved been so decided as to convince a judicious observer 
that it was not due to mental suggestion rather than to the 
physiologic activity of the drug itself. So few have been con- 
vinced of the efficacy of the remedy that it has already been 
practically abandoned. 

Upon the assumption that the ovary is a secreting gland, its 
substance has been recommended in a variety of conditions 
connected with menstruation, especially for the relief of the 



346 ANTIPYRETICS OR FEBRIFUGES. 

distressing symptoms attending the premature or artificial meno- 
pause. The results of its use, however, have not been very 
satisfactory ; moreover, there is no good reason for believing 
that the ovary has any other function than that of ovulation. 



ANTIPYRETICS OR FEBRIFUGES. 

The body derives its heat mainly from the oxidation of food- 
stuffs and from various mechanical movements, and loses it 
mainly by radiation and conduction from the skin and by the 
evaporation of water from the skin and lungs. Normally, 
heat-production and heat-dissipation are so evenly balanced 
that a mean temperature of 98.6 F. in the axilla is maintained, 
notwithstanding considerable variations in the surrounding 
temperature. The balance between income and expenditure 
is secured through the operation of a regulating mechanism 
located in the central nervous system. 

Antipyretics are drugs that lower temperature when it is 
abnormally high. They exert but little influence upon the 
normal temperature. Some of them, like acetanilid, phena- 
cetin, and antipyrin, act directly on the heat-regulating centers 
in such a way that the standard of temperature is brought to a 
lower level, where it is maintained for a limited period ; some, 
like alcohol, through their influence on the circulation, increase 
the dissipation of heat ; while others, like quinin, lessen the 
production of heat by retarding oxidation. 

Diaphoretics lower temperature by increasing the loss of 
heat due to the evaporation of sweat. 

Cold applications increase the heat-loss by conduction. 

Indication. — Antipyretics are employed to lower temper- 
ature in febrile states. They are indicated, however, only 
when the temperature is sufficiently high as to be in itself a 
source of actual danger or of considerable discomfort to the 
patient. When used repeatedly at short intervals, they are all 
more or less depressing. On the other hand, cold bathing 
has a stimulant as well as an antipyretic effect, and for this 
reason, when it can be carried out satisfactorily, it is always 
preferable to the use of drugs. 

The most important antipyretics are : 

Acetanilid, ""l Quinin. 

Antipyrin, ^ , . , . . • Guaiacol. 

Phenicetin, \ Coal - tar ^pyretics. Aconfe 

Phenocoll, J 



ACETANIL1DUM. 347 

Salicylic acid, carbolic acid, and resorcin also lower temper- 
ature in febrile states, but they are no longer used for this 
purpose. 

ACETANILIDUM, U. S. P. 

(Acetanilid ; Antifebrin; C 6 H 5 NH.C 2 H 3 0.) 

Acetanilid is a derivative of anilin, an atom of hydrogen in 
the latter being replaced by the acetic acid radical acetyl. It 
is a white, shining, crystalline powder, odorless, and of a 
faintly burning taste. It is soluble in 179 parts of water, in 
2.5 parts of alcohol, and in 12 parts of ether. The dose is from 
3-10 gr. (0.2-0.65 gm.). 

Preparation. Dose. 

Pulvis Acetanilidi Compositus, U. S. P. (acet- 
anilid, 70 parts ; caffein, 10 parts and so- 
dium bicarbonate, 20 parts) 5 -I 5 g r - (0-3- 1 - gm.). 

Physiologic Action. — In health, single, moderate doses 
(5-10 gr. — 0.3-0.65 gm.) of acetanilid produce no perceptible 
effect. In fever, however, they induce a marked fall in tem- 
perature, which usually begins within two or three hours, and 
lasts a variable time, generally four or five hours. The fall in 
temperature is often associated with free perspiration. The 
antipyretic action of the drug has not been satisfactorily ex- 
plained, but it appears to be the result of a direct influence 
exerted on the heat-regulating centers, in consequence of 
which the cutaneous vessels are dilated and the heat-dissipa- 
tion is increased. 

Circulation. — In ordinary doses acetanilid has no pro- 
nounced action on the circulation, a slight quickening of the 
pulse, however, is sometimes observed, which is probably the 
result of the direct action of the drug on the cardiac muscle. 

Blood. — After large doses the blood becomes of a choco- 
late color, owing to the production of methemoglobin. The 
corpuscles themselves, however, do not suffer disintegration 
unless the dose has been very large. 

Respiration. — The drug seems to have no direct action on 
respiration. In poisoning there is marked dyspnea, but this is 
probably due to the changes induced in the red blood-cells. 

Nervous System. — Our knowledge of the action of acetan- 
ilid on the nervous system is very vague. The fact that the 
drug relieves headache and neuralgic pain without affecting 



348 ANTIPYRETICS OR FEBRIFUGES. 

movement or consciousness shows that it has a special affinity 
for the sensory neurons, but as in large doses it induces more 
or less somnolence and paresis, it must affect also, though to a 
less extent, other portions of the nervous apparatus than the 
sensorium. Locally, on mucous membranes and raw surfaces 
it exerts an analgesic effect by depressing the peripheral sen- 
sory nerves. Bokai and others assert that in frogs it para- 
lyzes the motor nerve-endings also when directly applied. 

In animals, poisonous doses may excite convulsions, and 
these appear to be sometimes of spinal and sometimes of cere- 
bral origin. 

Metabolism. — The testimony as to the action of acetanilid 
upon nitrogenous elimination is so contradictory as to justify 
the conclusion that the drug has but little influence one way 
or the other upon tissue-metabolism. 

Absorption and Elimination. — Acetanilid is absorbed and 
eliminated with great rapidity. It is largely oxidized in the 
organism, and appears in the urine as the sulphate and glyco- 
uronate of paramidophenol. 

Action on Lower Organisms. — It has some power in in- 
hibiting the growth of bacteria, but its germicidal powers are 
feeble. 

Toxicology. — The chief symptoms of acetanilid poisoning 
are marked cyanosis, feeble breathing, extreme weakness of 
the circulation, free perspiration, dilatation of the pupils, and 
collapse. Treatment consists in maintaining the temperature 
of the body by means of external heat and in supporting the 
respiration and circulation by the liberal use of such drugs as 
strychnin, ammonia, and atropin. Artificial respiration and 
oxygen inhalations are useful in combatting the cyanosis. 

Untoward Effects. — Idiosyncrasies to acetanilid are not 
uncommon. Some persons are so susceptible to its action 
that cyanosis and collapse follow the administration of the 
drug even in small doses. Summers has reported an instance 
in which 4 grains, repeated in thirty minutes, caused cyanosis, 
partial loss of consciousness, and grave collapse in a healthy 
patient, who had many times previously taken the drug in 
much larger doses without ill effects. 

Fortunately, in the vast majority of such cases recovery 
follows under appropriate treatment. Papular and erythema- 
tous rashes are occasionally induced by acetanilid, but not so 
frequently as by antipyrin. 

Therapeutics. — Moderate doses of acetanilid (5 gr. — 0.3 
gm.) are sometimes useful in controlling the temperature in 



ACETANILIDUM. 349 

such diseases as typhoid fever, scarlet fever, and erysipelas. 
Nothing, however, is to be gained from the use of antipyretic 
drugs in these diseases when the temperature is not above 
103 ° F. or 103.5 ° F., and is not causing much inconvenience 
to the patient. They should be employed only when the tem- 
perature itself is exciting considerable discomfort or when it is 
so high as to exert a baleful influence upon the nutrition of the 
vital organs ; even then, hydrotherapy, on account of its stim- 
ulant effects, is always preferable if it can be satisfactorily car- 
ried out and is not precluded by some special feature of the case. 

In tuberculosis and other adynamic diseases coal-tar anti- 
pyretics, if used at all, must be used with the utmost caution. 

Acetanilid and its congeners, judiciously employed, are of 
great value in relieving certain forms of pain, particularly head- 
ache, neuralgia, migraine, the pai?is of influenza, and even the 
nerve-storms of locomotor ataxia, but they have little or no in- 
fluence upon the pain of acute inflammation, of traumatism, or 
of morbid growths. 

Acetanilid has been recommended as a depressomotor in 
epilepsy, chorea, and whooping-cough, but for this purpose it 
has been employed much less extensively than antipyrin. 

Externally, it has been frequently substituted for iodoform 
in the treatment of wounds, burns, ulcers, and chancroidal sores. 
Its advantages are its inexpensiveness and freedom from odor. 
It must be employed with some caution, as it may be absorbed 
in sufficient quantity to produce toxic symptoms. This use 
of the drug appears to be decidedly dangerous in young chil- 
dren, no less than 20 cases of poisoning from it in infants 
having been reported within recent years. 

Administration. — It may be administered in powders, 
capsules, tablets, or pills. When a prompt effect is desired, it 
should be given in solution, alcohol being used as a solvent 
before the diluent is added. 

Incompatibles. — With alkaline bromids and iodids, in 
aqueous solution, it forms insoluble compounds. When tritu- 
rated with antipyrin, chloral, thymol, or resorcin, it forms a 
semiliquid mass. When added to spirit of nitrous ether, the 
solution after a time turns yellow and then red. 

Bxalgin or methyl-acetanilid is also a derivative of 
anilin. It has no advantages over acetanilid, which it resem- 
bles very closely in its action. It has been used more as an 
analgesic than as an antipyretic. The dose is from 3-10 gr. 
(0.2-O.6 gm.). 



350 ANTIPYRETICS OR FEBRIFUGES. 

ANTIPYRINA, U. S. P. 

(Antipyrin; Phenazon; Phenyl-dimethyl-pyrazolon ; C 6 H 5 (CH 3 ) 2 C3HN a O.) 

Antipyrin is a synthetic base obtained by acting on phenyl- 
hydrazin (an anilin derivative) with diacetic ether, and then 
methylating the resulting monoethyl compound. It occurs 
in white, crystalline scales, odorless, and of a somewhat bitter 
taste. It is freely soluble in water, alcohol, and chloroform. 
The dose is from 3—15 gr. (0.2—1.0 gm.). 

Physiologic Action. — The action of antipyrin, so far as 
it is definitely known, closely resembles that of acetanilid. It is 
probably a little less toxic than acetanilid, although it is more 
prone than the latter to cause papular or erythematous skin 
eruptions. It is absorbed and eliminated very rapidly, most 
of it escaping un decomposed through the kidneys. 

Therapeutics. — Antipyrin is employed internally for the 
same purposes as acetanilid. Both are used to lower temper- 
ature in fever and to relieve pains of a neuralgic character. 
While the two drugs are equally efficacious, one sometimes 
succeeds where the other fails. 

Antipyrin has been used to a considerable extent as an 
antispasmodic. The diseases in which it is has acquired the 
most reputation in this respect are epilepsy and whooping- 
cough. 

In epilepsy it sometimes renders excellent service as an 
adjuvant to the bromids. From 10-15 gr. (0.6-1.0 gm.) a day 
may be given for three or four weeks, and then discontinued 
for two or three weeks before being resumed. The drug 
should be withdrawn at once, however, if cyanosis appear. 
In whooping-cough no remedy is so generally useful in con- 
trolling the paroxysms as antipyrin. It may be given by 
itself or in combination with a bromid, as in the following 
formula : 

R Antipyrinse, gr. 1 (3.2 gm.) ; 

Sodii bromidi, giss (6.0 gm.) ; 

Glycerini, f|ss (15.O c.c.) ; 

Aquae menthse piperita, q. s. ad f Jiij (90.0 c.c). M. 
Sig. A teaspoonful in water every three hours for a child of three 
years. 

Antipyrin is of some value in diabetes mellitus } but the 
manner of its action is unknown. Locally it has been recom- 
mended as an analgesic and as a hemostatic. As an analgesic 
it has been used with more or less success in relieving the 
pain of cancerous ulcers. Deep injections of a 50 per cent, 
solution have been employed also in lumbago and in sciatica y 



A CE TPHENE TIDINUM. 3 5 I 

but they are painful and liable to cause abscesses. As a 
hemostatic it sometimes is effective in arresting hemorrhage 
from small vessels ; thus solutions of from 5 to 10 per cent, have 
been found satisfactory in checking epistaxis and in controlling 
the capillary oozing after operations. In some persons its 
application in any strength proves irritating. 

Administration. — Antipyrin may be given by the mouth 
in the form of powders or capsules, but on account of its 
ready solubility it is perhaps best ordered in some aromatic 
water. In exceptional cases it may be administered hypoder- 
mically or by the rectum. 

Incompatibles. — On account of its basic properties anti- 
pyrin has a wide range of incompatibility. It is incompatible 
with iron salts, calomel, corrosive sublimate, iodin, iodids, ben- 
zoates, carbolic acid, ammonia water, sodium bicarbonate, 
nitrites, and all preparations containing tannic acid. When 
triturated with chloral, butyl-chloral, sodium salicylate, ortho- 
form, or beta-naphthol, it forms a semiliquid mass. When 
added to spirit of nitrous ether a green color results from the 
formation of iso-nitroso-antipyrin. 



ACETPHENETIDINUM, U. S. P. 

(Acetphenetidin ; Phenacetin ; C 6 H 4 .OC 2 H 5 .NHC 2 H 3 0.) 

Acetphenetidin, or phenacetin, is obtained by acting on para- 
phenetidin (an anilin derivative) with glacial acetic acid. In 
the reaction that takes place an atom of hydrogen in para- 
phenetidin is replaced by the acetic acid radicle, acetyl. It 
forms colorless, tasteless, inodorous scales, soluble in alcohol 
and in glycerin, but only sparingly so in cold water. The 
dose is from 5-10 gr. (0.3-0.65 gm.). 

Physiologic Action and Therapeutics. — The studies 
that have been made upon the action of phenacetin indicate 
that it exerts much the same influence as acetanilid and anti- 
pyrin, save that it is less toxic than either of these drugs. On 
the whole, it is the most satisfactory of the coal-tar antipy- 
retics, and when used in moderate doses, it is rarely followed 
by cyanosis, collapse, cutaneous eruptions, or other untoward 
effects. It may be employed with advantage as an antipyretic 
and analgesic in the same class of cases as that in which ace- 
tanilid has been found to be useful. 

Administration. — It may be given in pills, capsules, pow- 
ders, or tablets. 



352 ANTIPYRETICS OR FEBRIFUGES. 

Incompatibles. — Salicylic acid, iodin, carbolic acid, chloral 
hydrate, and oxidizing agents. 

I/actophenin. — This compound is closely allied to phenac- 
etin in that it is para-phenetidin with an atom of hydrogen 
replaced by the lactic acid radicle, lactyl, instead of by the 
acetic acid radicle, acetyl. In addition to being an antipyretic 
and analgesic it has some power as a somnifacient. The dose 
is from 5-15 gr. (0.3-1.0 gm.). 

Phenocoll Hydro chlorid. — This phenetidin derivative 
represents an attempt to produce a soluble phenacetin. Chem- 
ically, it is glycocoll para-phenetidin hydrochlorid. It is a 
white, crystalline powder, soluble in about 16 parts of water. 
It is readily decomposed by alkalis and alkaline carbonates. 
The dose is from 5-15 gr. (0.3-1.0 gm.). As an antipyretic 
and analgesic it appears to be a safe and an effective substitute 
for acetanilid and antipyrin. It has been used also in rheuma- 
tism and in malarial fever, but with very indifferent success. 

Apolysin, Citrophen, and Kryofin. — These compounds, 
all phenetidin derivatives, have been introduced as rivals of 
phenacetin. Apolysin differs from phenacetin in containing 
a citric acid radicle instead of an acetic acid radicle. Citrophen 
differs from apolysin in containing 3 phenetidin groups instead 
of 1 to the molecule of citric acid. Kryofin differs from phenac- 
etin in containing a methyl-glycollic acid radicle instead of 
an acetic acid radicle. The dose of any one of these com- 
pounds is from 5-15 gr. (0.3-1.0 gm.). 

OTHER ANTIPYRETICS, 

Quinin (seep. 416).— In health the bodily temperature is 
not appreciably lowered by quinin unless the dose be exces- 
sive, but in febrile states the drug usually exerts a marked 
antipyretic influence when given in doses of from 20 to 30 gr. 
(1.3-2.0 gm.). This effect on the temperature cannot be 
attributed to an action on the heat-regulating centers, since it 
occurs after section of the spinal cord ; it appears to be due 
rather to an interference with metabolism, in consequence of 
which there is a decrease in the production of heat. 

The best results are obtained by giving the drug in one 
large dose a few hours before a natural remission is expected 
to occur. As a matter of fact, however, quinin is rarely used 
as an antipyretic at the present time. When it is deemed 
necessary to lower the temperature by means of drugs, the 
coal-tar derivatives, on account of the certainty and prompt- 
ness of their action, the ease with which thev can be admin- 



ASTRINGENTS. 353 

istered, and their power to relieve headache and other pains 
incident to fever, are preferable to quinin, which lacks these 
advantages, and which, moreover, often disturbs the stomach. 

Guaiacol (see p. 286). — In febrile diseases guaiacol, applied 
to the skin, acts as a prompt and powerful antipyretic. To 
secure the desired effect about 30 min. (2.0 c.c.) should be 
slowly rubbed into the skin of the abdomen with a camel's- 
hair brush, and the part subsequently covered with a piece of 
waxed paper to prevent evaporation. The absorption of the 
drug, which usually occurs in a few minutes, is followed by a 
gradual fall of temperature, the lowest point being reached 
about three hours after the application. The reduction of 
temperature is associated with profuse perspiration, and is 
followed shortly by a rapid return of the fever, with marked 
chilliness. The applications, especially if made repeatedly, 
often cause considerable depression, and for this reason guaia- 
col cannot be recommended as an antipyretic, except for occa- 
sional use. 

Aconite (see p. 60). — Compared with the coal-tar deriva- 
tives, aconite is but a feeble antipyretic. It lowers tempera- 
ture probably through a central action, but this has not been 
definitely established. On account of its sedative influence on 
the circulation it is a useful febrifuge in acute inflammatory con- 
ditions and in the febrile diseases of childhood when the pulse 
is rapid and strong. It is contraindicated in asthenic fevers. 
The best results are obtained by giving the tincture in small 
doses at frequent intervals. Spirit of nitrous ether and the 
solution of ammonium acetate are useful synergists. 



ASTRINGENTS. 

Astringents are substances which, by their direct action, 
cause contraction or condensation of the tissues. Their influ- 
ence is most marked upon raw surfaces and mucous mem- 
branes. Many of them have also the property of diminishing 
or arresting glandular secretion, and this they accomplish not 
so much by constricting the blood-vessels of the part as by 
affecting the secreting cells directly. While their action is 
probably due in part simply to shrinking of the protoplasm, 
it is undoubtedly chiefly due to precipitation or to coagulation 
of the albumin of the cells. 

Astringents are divided into two classes, vegetable and min- 
eral. The former owe their efficacy to the presence of tannic 

23 



354 



ASTRINGENTS. 



acid. There are but few astringents that are not also irritants, 
especially if employed in concentrated form. Some of the 
metallic salts are more irritant and caustic in their action than 
they are astringent. This is due in one instance to the irritant 
properties of the acid liberated by the union of the metal with 
the albumin of the cells ; in another instance to the intensely 
toxic nature of the metal itself; and instill another instance to 
the permeable texture of the coagulum that is formed by the 
first application of the salt. 

Among the mineral astringents, the insoluble salts of bis- 
muth, zinc oxid, and lead acetate have more of a sedative than 
an irritant action. 

The chief vegetable astringents are : 

Tannic acid. Gambir. 

Gallic acid. Geranium. 

Galls. Hematoxylon. 

Kino. Sumac. 

Krameria. Oak bark. 
Hamamelis. 

The chief mineral astringents are : 

Alum. Zinc oxid. 

Lead acetate. Silver nitrate. 

Copper sulphate. Bismuth subnitrate. 

Zinc sulphate. Bismuth subcarbonate. 

Calcium carbonate. 

Iron salts (see p. 289) and weak solutions of mineral acids, 
especially sulphuric acid (see p. 448), also have an astringent 
action. 

Indications. — The very mild astringents, like bismuth 
subnitrate and zinc oxid, are useful as protectives in acute 
superficial inflammations ; the more active ones, like the tannic 
acid compounds and zinc sulphate, are employed to lessen the 
excessive secretion often remaining as a sequel of acute in- 
flammation of mucous membranes. Some astringents, like 
alum and tannic acid, are also used to check hemorrhage, 
their styptic properties depending upon their power to coagu- 
late the albumin of the blood. 

ACIDUM TANNICUM, U. S. P. 

(Tannic Acid ; Tannin; Gallotannic Acid ; HC u H g 9 .) 

Tannic acid is the active constituent of all the vegetable 
astringents. It is derived from the nutgall, which contains 



ACIDUM TANNIC 'UM. 



355 



from 30 to 60 per cent, of it. The pure acid is a light-yellow- 
ish, amorphous powder, almost odorless, and of a strongly 
astringent taste. It is soluble in about 0.34 part of water, in 0.23 
part of alcohol, and in 1 part of glycerin. The dose is from 
3-10 gr. (0.2-0.6 gm.). 

Preparations. 
Collodium Stypticum, U. S. P. (20 per cent.). 
Glyceritum Acidi Tannici, U. S. P. (20 per cent.). 
Unguentum Acidi Tannici, U. S. P. (20 per cent.). 
Trochisci Acidi Tannici, U. S. P. (l gr.— 0.06 gm. — in each). 

Physiologic Action. — When applied to raw surfaces 
tannic acid precipitates the albumin of the superficial cells and 
causes condensation of the tissues. At the same time it lessens 
the sensibility of the peripheral nerves. On mucous mem- 
branes it acts in a similar manner, but more decidedly, and in 
addition dries up secretion by combining with the proteids of 
the glandular cells. Whether or not it constricts the blood- 
vessels with which it comes in contact is a mooted question. 
It coagulates blood, and thus serves as a local styptic. It is said 
also to inhibit the diapedesis of the leukocytes. When taken 
internally, the acids of the gastric juice prevent it from form- 
ing a permanent union with any proteids that may be present, 
so that it is free to act as an astringent in both the stomach 
and bowel. In moderate doses it impairs digestion and causes 
constipation ; in very large doses it acts as an irritant and ex- 
cites vomiting and diarrhea. 

In the intestine, tannic acid is transformed into gallic acid, 
and in this form a certain amount is absorbed and is subse- 
quently eliminated in the urine. 

Therapeutics. — Locally, tannic acid is much used to 
check excessive secretion and to impart tone to relaxed mu- 
cous membranes. In subacute and chronic laryngitis and 
pharyngitis a solution of from 1-5 gr. (0.06-0.3 gm.) to the 
ounce (30.0 c.c.) makes a useful spray. Some surgeons have 
found injections of the glycerite, more or less diluted, efficacious 
in subacute and chronic urethritis. The same preparation is 
frequently beneficial in chronic vaginitis, leukorrhea, erosion of 
the uterine cervix, and chronic cervical endometritis. Lotions 
and dusting-powders containing tannin sometimes act favor- 
ably in hyperidrosis of the feet. 

When it can be brought in direct contact with a bleeding 
surface tannic acid is a reliable hemostatic. In epistaxis strips 
of lint spread with vaselin and tannic acid make an excellent 
tampon. In hematemesis or enterorrhagia the drug may be 
given in full doses by the mouth. As it is absorbed in the 
form of gallic acid, which has no styptic power, it is valueless 



356 AS TR INGE NTS. 

as an internal remedy in hemorrhages outside of the aliment- 
ary canal. 

As it forms more or less insoluble tannates with tartar 
emetic and the vegetable alkaloids, it may be employed as a 
chemical antidote in poisoning by one of these drugs. Can- 
tani and others have spoken highly of enteroclysis with a hot 
tannic acid solution (2 per cent.) in Asiatic cholera. 

Administration. — When its action is desired in the stom- 
ach, tannin should be given in powder ; if the intestine is to be 
reached, it should be given in pill. 

Incompatibles. — Alkaloids, gelatin, lime-water, tartar 
emetic, and the salts of iron, silver, lead, and copper. When 
tannic acid is triturated with potassium chlorate the mixture 
explodes with great violence; hence, when these two drugs 
are to be combined in solution, they should be dissolved sepa- 
rately before being brought together. 

Tannalbin, Tannigen, and Tannoform. — In the last 
few years several attempts have been made to enhance the 
therapeutic value of tannic acid as an intestinal astringent by 
converting it into compounds that will pass through the stom- 
ach unchanged and will be decomposed in the intestine, set- 
ting free the acid. The most important of these new com- 
pounds are tannalbin, tannigen, and tannoform. 

Tannalbin is a light-brown, odorless and tasteless powder, 
containing about 50 per cent, of tannin. It is prepared by 
subjecting tannin albuminate to dry heat for a considerable 
time. The dose for adults is from I5~20gr. (1. 0-1.3 gm.), in 
powders or cachets ; for children, from 5-15 gr. (0.3-1.0 gm.), 
in some mucilaginous vehicle or in powders. 

Tannigen is an acetic ester of tannic acid, and appears as a 
yellowish, odorless, almost tasteless, hygroscopic powder, in- 
soluble in water. As in the case of tannalbin, its astringent 
properties are not manifested until it reaches the bowel, where 
its decomposition is effected. It may be given in the same 
dose as tannalbin. 

Experience in the use of these two remedies warrants the 
opinion that they may be used interchangeably ; that they are 
free from irritant properties, even when administered in large 
amounts ; and that they have a definite, if but limited, field of 
usefulness in the treatment of acute intestinal catarrh. The 
chief indication for their employment is the continuation of 
profuse and watery discharges after the cause of the inflam- 
mation has been completely removed. In chronic diarrhea 
and in dysentery they usually prove disappointing, and in 
tuberculous enteritis, of course, no favorable results from them 
are to be expected. 



ACIDUM GALLICUM—GALLA. 357 

Tannoform is a combination of tannic acid and formaldehyd. 
It appears as a pale-pink powder, insoluble in water. It 
escapes decomposition in the stomach, but in the intestine is 
slowly broken up, yielding free tannin and formaldehyd. The 
dose for an adult is from 3-5 gr. (0.2-0.3 gm.) ; for a child, 
1-3 gr. (0.06-0.2 gm.). It has been recommended in intestinal 
catarrh, but it is most too irritating for internal use. As an 
external remedy, however, it is not without value. A mixture 
of tannoform 1 part and Venetian talc 2 parts often acts very 
favorably in excessive sweating of the feet, especially when 
there is more or less maceration of the tissues. 

ACIDUM GALLICUM, U. S. P. 

(Gallic acid; HC 7 H 6 5 + H 2 0.) 

Gallic acid is the hydrid of tannic acid, from which it is 
usually prepared by boiling with dilute sulphuric acid. It 
occurs in white or pale-fawn colored, silky needles, odorless, 
of an astringent or slightly acidulous taste, and permanent in 
the air. It is soluble in 84 parts of water, in 4 parts of alco- 
hol, and in 12 parts of glycerin. It differs from tannic acid in 
not precipitating gelatin, albumin, or alkaloids. The dose is 
from 5-20 gr. (0.3-1.3 gm.) in powders or capsules. 

Physiologic Action and Therapeutics. — Locally, gal- 
lic acid is a very feeble astringent, but as it does not coagu- 
late blood, it cannot be recommended as a styptic. When 
taken internally, it is absorbed into the blood and is eliminated 
unchanged in the urine. It has an undeserved reputation as a 
remote astringent in checking hemorrhages from parts that 
can be reached only through the circulation, in controlling 
night-sweats, and in diminishing the excessive secretion of 
urine in diabetes insipidus. 

Incompatibles. — Ferric salts, tartar emetic, lead acetate, 
silver nitrate, and spirit of nitrous ether. 

GALLA, U. S. P. 

(Nutgall; Gall.) 

Galls are excrescences produced by the stings and deposited 
ova of an insect in the bark or leaves of a plant. The official 
galls are caused by a species of cynips, which deposits its eggs 
in the tender shoots of Quercus infectoria y an oak growing in 
the countries bordering on the Mediterranean. Their thera- 
peutic activities depend upon tannic acid, of which they contain 
from 30 to 60 per cent. 

Preparations. Dose. 

Tinctura Gallse, U. S. P \-2 fl. dr. (2.0-8.0 c.c). 

Unguentum Gallse, U. S. P. (20 per cent.). 



35^ ASTRINGENTS. 

Therapeutics. — Neither galls themselves nor the tincture 
are at the present time used internally. Nutgall ointment 
with equal parts of stramonium ointment is a time-honored 
remedy in painful hemorrhoids. 

KINO, U. S. P., KRAMERIA, U. S. P., AND 
GAMBIR, U. S. P. 

Kino is the inspissated juice of Pterocarpus Marsupium, a 
large tree growing in the East Indies. The dose of the pow- 
dered drug is from 5-30 gr. (0.3-2.0 gm.). 

Preparation. Dose. 

Tinctura Kino, U. S. P \-2 fl. dr. (2.0-8.0 c.c). 

Krameria, or rhatany, is the root of Krameria triandra, a 
low shrub growing on the mountains of Peru and Bolivia. 

Preparations. Dose. 

Tinctura Krameriae, U. S. P \-2 fl. dr. (2.0-8.0 c.c). 

Syrupus Krameriae, U. S. P. (contains 45 

per cent, by volume of the fluid extract) . 1-2 fl. dr. (4.0-8.0 c.c). 

Fluidextractum Krameriae, U. S. P. ... 5-30 min. (0.3-2.0 c.c). 

Extractum Krameriae, U. S. P 5-10 gr. (0.3-0.6 gm.). 

Trochisci Krameriae, U. S. P. (each con- 
tains about I gr. — 0.06 gm. — of the ex- 
tract). 

Gambir is an extract prepared from the leaves and twigs of 
Ourouparia Gambir, a climbing plant of the East Indies. It 
was introduced into the Pharmacopeia to take the place of 
catechu (U. S. P. 1 890), as the wood from which the latter is 
extracted is difficult to obtain. 

Preparations. Dose. 

Tinctura Gambir Compositae, U. S. P. (5 

per cent., with Saigon cinnamon 2.5 per 

cent.) \-2 fl. dr. (2.0-8.0 c.c). 

Trochisci Gambir, U. S. P. (each contains 

about I gr. — 0.06 gm.). 

Therapeutics. — All these drugs contain large amounts of 
tannic acid, to which their astringent properties are due. They 
are sometimes employed to check excessive secretion in acute 
diarrhea. They should never be given, however, until the bowel 
has been thoroughly cleared of irritant material. They are often 
prescribed with chalk and opium, as in the following formula : 

R Cretae praeparatae, gij (8.0 gm.) ; 

Tinctura? opii deodorati, ll^xx (1.3 c.c); 

Tincturae krameriae, f^ij(S.occ); 

Acaciae, q. s. ; 

Aquae cinnamomi, q. s. ad f ^iij (90.0 c.c). M. 

Sig. A teaspoonful every two or three hours for a child of two 
years. 



GERANIUM— RHUS GLABRA. 359 

Troches of krameria or of gambir are useful in relaxed sore 
throat, 

GERANIUM, U. S. P. 

(Cranesbill.) 

Geranium is the rhizome of Geranium maculatum, a peren- 
nial herb growing in the woody places of North America. It 
contains from 10 to 28 per cent, of tannic acid. 

Preparation. Dose. 

Fluidextractum Geranii, U. S. P ^-1 fl. dr. (2.0-4.0 c.c). 

Therapeutics. — Geranium is the therapeutic equivalent of 
kino, krameria, and gambir, for which it may be substituted 
with advantage on account of its less disagreeable taste. 

HiEMATOXYLON, U. S. P. 

(Hematoxylon ; Logwood.) 

Hematoxylon is the heart-wood of Hcematoxylon campechia- 
num, a small tree growing in Central America and the West 
Indies. Its chief constituents are tannin and a crystalline color- 
ing principle, hematoxylin. 

Preparation. Dose. 

Extractum Haematoxyli, U. S. P 5 _ 3° g 1 "- (0.3-2.0 gm.). 

Therapeutics. — Logwood is used chiefly as an astringent 
in the diarrhea of young children. It is less active than kino, 
krameria, or gambir, but more agreeable on account of its 
sweetish taste. It has a disadvantage in staining the diapers 
a blood-red color. Hematoxylin is not used medicinally, but 
it is extensively used for its tinctorial properties in preparing 
tissues for microscopic study. 

RHUS GLABRA, U. S. P. 

(Sumac.) 

Sumac is the fruit of Rhus glabra, a shrub growing in waste 
places in North America. It contains, in addition to tannic 
acid, several acid mallates. 

Preparation. 
Fluidextractum Rhois Glabrae, U. S. P. 

Therapeutics. — Sumac is never used internally, but the 
fluid extract, diluted with from 6 to 8 parts water, makes an ex- 
cellent mouth-wash or gargle in mercurial stomatitis and in acute 
pharyngitis, especially if a small amount of potassium chlorate 
be added, as in the following formula : 



360 ASTRINGENTS. 

R Potassii chloratis, £j (4.0 gra.) ; 

Fluidextracti rhois glabrae, f Jy (30.0 c. c. ) ; 

Aquae, q. s. ad f gviij (250.0 c. c). — M. 

Sig. Use as a gargle. 



QUERCUS, U. S. P. 

(Quercus Alba; White Oak.) 

Quercus is the bark of Quercus alba, a large tree growing 
in North America east of the Mississippi. It contains from 
5 to 10 per cent, of tannin and a bitter principle, quercin. 

Therapeutics. — In the form of a decoction (1 oz. : 1 pint 
— 30.0 gm. : 0.5 L.) it is occasionally used as a gargle in sore 
throat or as an injection in leukorrhea. 

HAMAMELIS. 

(Witch-hazel.) 

Hamamelis is official as the bark (Hamamelidis Cortex) 
and the dried leaves (Hamamelidis Folia) of Hamamelis vir- 
giniana, a shrub widely distributed throughout North America. 
It contains a volatile oil, a small amount of tannin, and a bitter 
principle. 

Preparations. Dose. 

Fluidextractum Hamamelidis Foliorum, U. S. P. %-l fl. dr. (2.0-4.0 c.c). 
Aqua Hamamelidis, U. S. P 1-4 fl. dr. (4.0-15.0 c.c). 

Physiologic Action and Therapeutics. — Although ex- 
aminations of witch-hazel have not revealed the presence of 
any very active ingredient, the drug is credited with consider- 
able power as an astringent, a hemostatic, and a sedative. 
Dujardin-Beaumetz was of the opinion that it exerted a tonic 
influence upon the muscular coats of the blood-vessels, but 
the investigations of Guy and of Wood indicate that it has no 
such action. According to Ringer, large doses sometimes 
cause severe headache. 

Hamamelis water has a popular reputation as a topical 
remedy for sprains, bruises , and small wounds. As an injec- 
tion or lotion it makes a very soothing application in painful 
hemorrhoids. Diluted with water, 1 part to 3, it is used with 
benefit as a spray in acute coryza. Both the water and the 
fluid extract have been used internally in various hemorrhages 
with asserted good results. 



A LUMEN. 361 

ALUMEN, U. S. P. 

(Alum; Potassium Alum; Aluminum and Potassium Sulphate; A1K(S0 4 ) 3 + 

I2H 2 0.) 

The alum of the United States Pharmacopeia is a double 
sulphate of aluminum and potassium. In the British Phar- 
macopeia both this salt and the double sulphate of aluminum 
and ammonium are official. These compounds are of equal 
value. Potassium alum occurs in large, colorless, octahedral 
crystals, odorless, and of a sweetish and strongly astringent 
taste. It is freely soluble in water and in warm glycerin, but 
it is insoluble in alcohol. The usual dose is from 5-15 gr. 
(0.3-1.0 gm.), but as an emetic from 1-2 dr. (4.0-8.0 gm.) may 
be given. 

Preparation. 
Alumen Exsiccatum, U. S. P. (dried or burnt alum). 

Physiologic Action. — When applied to the broken skin 
or to mucous membranes, alum acts as a powerful astringent, 
precipitating the albumin of the superficial cells, coagulating 
the fluids, and contracting the tissues. When used too freely 
or in the form of dried alum, it acts as an irritant. It forms 
a firm coagulum with blood, and thus tends to arrest hemor- 
rhage. Taken internally in small doses it has an astringent 
effect and causes constipation. Large doses usually excite 
vomiting, but if retained, they induce gastro-enteritis. 

Therapeutics. — Alum may be used as a local styptic in 
arresting hemorrhages from small wounds. A solution of from 
\- 1 dr. (2.0-4.0 gm.) to the pint (0.5 L.) is sometimes effica- 
cious in leukorrhea. Insufflations of dried alum (1 : 20 of 
starch) or sprays of a weak solution — 5-10 gr. (0.3-0.6 gm.) to 
the ounce (30.0 c.c.) — are sometimes of service in subacute and 
chronic pJiaryngitis and laryngitis, especially when there is 
much mucous secretion. Its prolonged use in the mouth is 
contraindicated on account of its destructive action on the 
teeth. Lotions of alum and diluted alcohol are sometimes 
employed in hyperidrosis. Dried alum has long been used as 
a mild caustic for destroying exuberant granulations. 

Internally alum is no longer in use as an astringent. It is, 
however, a safe but somewhat uncertain emetic, and may be 
given to children in doses of a teaspoonful of the powdered 
drug in syrup, repeated once or twice if vomiting does not 
follow. 

Incompatibles. — Alkalis and their carbonates, lead ace- 
tate, mercury, iron salts, and tannic acid. 



362 ASTRINGENTS. 

PLUMBUM. 

(Lead; Pb.) 

Metallic lead is obtained from a native sulphid and is not 
official ; the following preparations, however, are recognized by 
the United States Pharmacopeia: Acetate, subacetate, oxid, 
nitrate, and iodid. 

Physiologic Action. — Upon the skin soluble lead-salts 
have little or no effect, but when applied to denuded surfaces 
or to mucous membranes, they act as astringents, combining 
with the albumin of the cells and fluids to form a delicate but 
impervious coagulum. Unless applied in concentrated form 
they exert, with the exception of the nitrate, a sedative rather 
than a corrosive action. 

Taken internally, single, moderate doses of lead acetate 
have no action outside of the alimentary canal. They leave a 
sweetish, metallic taste in the mouth, with a feeling of dryness, 
and, owing to their astringent effects, they tend to cause con- 
stipation. Most of the drug escapes absorption and is dis- 
charged in the stools in the form of a sulphid. In very large 
doses lead acetate acts as an irritant poison and excites pain 
in the stomach, nausea and vomiting, great thirst, diarrhea, or, 
more rarely, constipation, and collapse. Death is often pre- 
ceded by coma and convulsions. The form in which lead is 
absorbed is not definitely known, but it is presumed that it 
circulates as an albuminate. It is eliminated in the urine, bile, 
intestinal secretions, saliva, and milk, and probably, also, in 
the sweat. Ordinarily its excretion is effected rather slowly, 
so that its continuous absorption, even in small quantities, is 
liable to lead to an accumulation of the metal in the tissues. 

Chronic I^ead-poisoning or Plumbism. — This con- 
dition may be brought about by the too prolonged use of the 
salts of lead for medicinal purposes, but it is much more fre- 
quently induced in workmen who are exposed to the fumes 
or dust of lead, or who handle the metal or paints containing 
it. It may follow, also, the accidental introduction of lead into 
the system through drinking-water, articles of food, hair-dyes, 
and cosmetics. 

Hard waters may be stored in cisterns lined with lead or 
may be conveyed through lead pipes without harm resulting, 
since they soon deposit on the metal an insoluble coating of 
lead sulphate ; on the other hand, soft waters, especially those 
containing considerable quantities of carbon dioxid, have a 
dangerous lead-dissolving action. 

Symptoms of Chronic Poisoning-. — The most common 



PLUMBUM. 363 

symptom is colic (colica pictonum). This condition consists in 
paroxysms of severe abdominal pain, with retraction and 
rigidity of the abdominal muscles and obstinate constipation, 
although rarely there may be diarrhea. During the attacks 
there is often a marked increase in the arterial tension and 
slowing of the pulse. A characteristic feature of plumbism is 
the blue line on the edge of the gums near the insertion of the 
teeth. This discoloration is due to the deposit of lead sulphid 
formed from the sulphureted hydrogen evolved in the decom- 
position of particles of food. Perfect cleanliness of the teeth 
may prevent its appearance. Lead palsy is of common occur- 
rence. It usually attacks the muscles supplied by the mus- 
culospiral nerve, — the extensors of the fingers and of the 
wrist, — causing the so-called " wrist drop." The affected mus- 
cles ultimately atrophy and yield the reactions of degenera- 
tion. Occasionally other muscles are involved, such as the 
extensors of the legs, the recti of the eye, and the adductors 
of the larynx. Lead-paralysis usually results from peripheral 
neuritis ; in some instances, however, there appears to be also 
degeneration of the ganglionic cells of the spinal cord, but 
whether this is primary or is secondary to the neuritis has not 
been determined. 

Anemia is rarely absent. Both the hemoglobin and the 
number of red cells are decreased, and, moreover, as Grawitz 
has shown, the red cells usually contain numerous basophilic 
granules. 

Cerebral symptoms (encephalopathia saturnina) occasionally 
occur. They include persistent headache, epileptiform con- 
vulsions, delirium, optic neuritis, stupor, and coma. A symp- 
tom-complex resembling paretic dementia has also been de- 
scribed. In some instances the cerebral symptoms are simply 
expressions of uremia, but in others they are the consequence, 
without doubt, of the toxic action of the lead itself. McCarthy 
has observed in dogs poisoned by lead degeneration of 
the ganglion-cells, increase in the gliar elements, and 
marked endarteritis. Finally, workers in lead are especially 
prone to chronic nephritis with arteriosclerosis and to gouty 
arthritis. 

Treatment of Lead-Poisoning-. — Acute Poisoning. — The 
stomach should be emptied by means of the stomach-pump, 
unless vomiting has rendered this procedure unnecessary. A 
soluble sulphate (Epsom or Glauber's salt) is a chemical anti- 
dote, forming with the lead an insoluble sulphate ; it should 
be given in excess, so that a purgative effect may also be 
secured. The resulting gastro-enteritis should be treated by 



364 ASTRINGENTS. 

the application of warm fomentations and by the administra- 
tion of opium and demulcent drinks. 

Chronic Poisoning. — Much may be done to prevent plumb- 
ism in lead-work establishments. Absolute cleanliness, espe- 
cially of the hands and nails, is of the utmost importance. 
Fans and suitable means of ventilation should be provided 
wherever dust is generated. Respirators should be worn by 
persons employed in dry processes. No food should be eaten 
in any part of the works. 

Curative treatment consists in eliminating the poison and in 
relieving the immediate symptoms. Potassium iodid, in doses 
of from 5-15 gr. (0.3-1.0 gm.) thrice daily, is employed to 
meet the first indication. Sulphur baths are also recommended. 
They are prepared by mixing in a wooden tub 3 or 4 oz. 
(90.0-125.0 gm.) of potassium sulphuret with about 20 gallons 
(75.0 L.) of water. Constipation should be relieved by saline 
cathartics, preferably by Epsom salts, or, if necessary, by elate- 
rium. Colic will require hot applications and hypodermic 
injections of morphin and atropin. For the paralysis, massage, 
electricity, and strychnin should be used. 

PLUMBI ACETAS, U. S. P. 

(Lead Acetate; Sugar of Lead; Pb (C,H 3 2 ) 2 + 3H 2 0.) 

Lead acetate occurs in heavy, colorless, efflorescent, pris- 
matic crystals or crystalline masses, having a sweetish, metallic 
taste, and a faintly acetous odor. It is soluble in 2 parts of 
water and in 30 parts of alcohol. The dose is from 1-4 gr. 
(0.065-0.26 gm.) in pills. 

Therapeutics. — Internally, pills of lead acetate and opium 
are sometimes useful in controlling subacute and chronic diar- 
rhea. Solutions of from 1-5 gr. (0.06-0.3 gm.) to the ounce 
(30.0 c.c), employed as injections, are of service in the station- 
ary stage of gonorrhea. 

The well-known " lead-water and laudanum " is usually 
made of the subacetate of lead, but the acetate may be sub- 
stituted with advantage, as in the following formula : 

R Plumbi acetatis, gj (4.0 gm.) ; 

Tincturae opii, f ,^j (3°-° c.c.) ; 

Aquae, q. s. ad f 3viij (236.0 c.c). — M. 

Although the ingredients in this combination are chemically 
incompatible, the mixture makes a useful sedative applica- 
tion in bruises, sprains, superficial inflammation, and erysipelas. 



PLUMBUM. 365 

Incompatibles. — Acids, alkalis, sulphates, carbonates, 
chlorids, and tannin. 

PLUMBI SUBACETAS. 
(Lead Subacetate ; Pb 3 (C 2 H 3 2 ) 2 .) 

The subacetate of lead is so unstable that it is employed 
only in solution. 

Preparations. 
Liquor Plumbi Subacetatis, U. S. P. (Goulard's extract: contains 25 

per cent, of lead subacetate) . 
Liquor Plumbi Subacetatis Dilutus, U. S. P. (lead-water : contains I 

per cent, of lead subacetate). 
Ceratum Plumbi Subacetatis, U. S. P. (Goulard's cerate : contains 20 
parts each of the solution of lead subacetate, wool-fat, and paraffin ; 38 
parts of white petrolatum, and 2 parts of camphor. 

Therapeutics. — The solution of the subacetate of lead, 
diluted with 3 or 4 parts of water, is employed as a sedative 
lotion in acute eczema, rhus poisoning, and erysipelas. The 
official diluted solution is too weak to be of much service, 
although it is often used in preparing " lead-water and lauda- 
num " (2 parts of lead- water to 1 part of laudanum). The 
cerate is occasionally used as an application for chapped hands. 

OLEATUM PLUMBI. 

(Oleate of Lead ; Pb2C, 8 H 33 2 . ) 

Oleate of lead is official as lead-plaster {Emplastrum Plumbi), 
which is prepared by stirring together hot solutions of lead 
acetate and soap. Lead plaster makes a useful protective 
dressing for superficial ulcers and bed-sores. An ointment com- 
posed of equal parts of lead-plaster and of vaselin makes an 
efficacious application in subacute eczema and hyperidrosis. In 
the latter affection, after the parts have been cleaned and dried, 
the ointment should be applied on strips of muslin, and renewed 
twice daily for two or three weeks, instructions being given to 
avoid washing the feet in water during the progress of the 
treatment. Lead-plaster also enters into diachylon ointment 
(Unguentum Diachylon, U. S. P.) and into all of the official 
plasters. 

PLUMBI NITRAS, U. S. P. 

(Lead Nitrate ; Pb(N0 3 ) 2 .) 

Lead nitrate occurs in white, translucent, octahedral crystals, 
odorless, and of a sweetish, astringent, and metallic taste. It 
is soluble in 2 parts of water. 



366 ASTRINGENTS. 

Therapeutics. — At the present time lead nitrate is em- 
ployed only as a caustic in the treatment of onychia. It is 
usually applied as a powder. 

PLUMBI IODIDUM, U. S. P. 

(Lead Iodid; Pbl,.) 

Lead iodid is a heavy, bright yellow powder, odorless and 
sparingly soluble in water and in alcohol. It owes its activity 
more to the iodin element than to the lead, and is used only as 
a local absorbent (see p. 317). 

PLUMBI OXIDUM, U. S. P. 

(LeadOxid; Litharge; PbO.) 

Lead oxid is a heavy, reddish-yellow powder, odorless and 
tasteless, and insoluble in ordinary menstrua. 

It is rarely employed except in preparing the solution of 
lead subacetate {Liquor Plumhi Subacetatis, U. S. P.). 

CUPRI SULPHAS, U. S. P. 

(Copper Sulphate; Blue Vitriol; CuS0 4 -f- 5H 2 0.) 

Copper sulphate occurs in large, transparent, deep-blue 
crystals, odorless, and of a nauseous, metallic taste. It is solu- 
ble in 2.2 parts of water and in 400 parts of alcohol. The dose 
as an astringent is from J-i gr. (0.016-0.06 gm.) ; as an emetic, 
5-10 gn (0.3-0.6 gm.). 

Physiologic Action. — Upon mucous membranes and raw 
surfaces copper sulphate in dilute form acts as an astringent ; in 
concentrated forms it acts as a mild caustic. Taken internally 
in large doses it causes emesis by its direct irritant action on 
the stomach. 

Toxicology. — Acute copper-poisoning is characterized by 
severe abdominal pain, a metallic taste in the mouth, and 
violent vomiting and purging, the ejecta often being mucous 
and bloody. Death may be preceded by delirium, convulsions, 
and coma. The bluish or greenish color of the vomit may 
serve to distinguish it from poisoning by other irritants. After 
death the gastro-intestinal tract is found to be intensely in- 
flamed, and sometimes ulcerated. Unless death occurs quite 
promptly, there may be found also fatty changes in the liver 
and kidneys. 

Treatment. — The antidotes are potassium ferrocyanid, 
magnesia, sodium carbonate, and soap. Demulcents like milk 
and eggs should be given freely. Opium will be required to 
relieve the pain. 



ZINCUM. 367 

Chronic copper-poisoning is of doubtful occurrence; it is 
said to occasion gastro-intestinal disturbances, cachexia, a 
green line on the gums, and a greenish discoloration of the 
hair. 

Therapeutics. — Copper sulphate is a prompt and power- 
ful emetic, but it is most too irritant for ordinary use. When 
administered once without effect it is best not to repeat the 
dose. In phosphorus poisoning it is useful not only as an 
emetic, but also as an antidote, since it forms on the phos- 
phorus an insoluble coating. 

In indolent ulcers, ulcerative stomatitis, chronic granular con- 
junctivitis (trachoma), light applications of the solid crystal are 
often very useful for their stimulant effects. In gonorrhea, 
after the acute symptoms have subsided, an injection contain- 
ing 2 gr. (0.13 gm.) to the ounce (30.0 c.c), gradually increased 
in strength, is quite efficacious. 

Internally, in pill form combined with opium, it is some- 
times of service in obstinate chronic diarrhea. 



ZINCUM, U.S. P. 

(Zinc; Zn.) 

Metallic zinc is official in the form of thin sheets, or in 
irregular granulated pieces, or molded into thin pencils, or 
in a state of fine powder. The metal itself is not used medi- 
cinally. 

ZINCI SULPHAS, U. S. P. 

(Zinc Sulphate; White Vitriol; ZnS0 4 -f- 7H 2 0.) 

Zinc sulphate occurs in colorless, transparent, rhombic crys- 
tals, odorless, and of an astringent metallic taste. It is soluble 
in 0.53 part of water and in 3 parts of glycerin, and is insoluble 
in alcohol. The dose as an astringent is from J— 3 gr. (0.03- 
0.2 gm.); as an emetic, 10-30 gr. (0.6-2.0 gm.). 

Physiologic Action. — In weak solution zinc sulphate 
exerts an astringent effect ; in concentrated solution, an irritant 
or caustic effect. Administered by the mouth, large doses (20 
gr. — 1.3 gm.) excite emesis through their action on the stomach. 
Toxic doses induce severe gastro-enteritis. 

The treatment of poisoning consists in the free exhibition 
of alkalis or their carbonates, and of demulcents like eggs and 
milk. 



368 ASTRINGENTS. 

Therapeutics. — A solution containing \ gr. (0.03 gm.) 
gradually increased to 5 or 6 gr. (0.3-0.4 gm.) to the ounce (30.0 
c.c.) makes an excellent injection in gonorrhea after the sub- 
sidence of acute symptoms. Weak solutions are sometimes of 
service in leukorrhea. 

R Zinci sulphatis, 

Aluminis, aa ^iss (5.8 gm.) ; 

Glycerini, f^vj (180.0 c.c.). — M. 

Sig. Add a tablespoonful to a quart of hot water, and use as an 
injection. 

A solution of from 1-2 gr. (0.06-0.1 gm.) to the ounce (30.0 
c.c.) is a favorite collyrium in the later stages of simple conjunc- 
tivitis. 

Internally, zinc sulphate is used as an emetic (see p. 167), 
and very rarely as an astringent in chronic diarrhea. 

Incompatibles. — Alkalis and their carbonates, vegetable 
astringents, lead acetate, silver nitrate, and lime-water. 

ZINCI ACETAS, U. S. P. 

(Zinc Acetate; Zn (C 2 H 3 2 ) 2 + 2H 2 0.) 

Zinc acetate occurs in thin, colorless, six-sided plates, of a 
pearly luster, an acetous odor, and an astringent, metallic taste. 
It is soluble in 2.5 parts of water and in 36 parts of alcohol. 
It is used as an astringent for the same purposes as zinc 
sulphate. 

ZINCI OXIDUM, U. S. P. 

(Zinc Oxid; ZnO.) 

Zinc oxid is an amorphous white powder, free from odor 
and taste, and insoluble in water and in alcohol. The dose is 
from 1-5 gr. (0.06-0.3 gm.) in pill. 

Preparation. 
Unguentum Zinci Oxidi, U. S. P. (contains 20 per cent, of zinc oxid). 

Therapeutics. — The ointment of zinc oxid is extensively 
used as a slightly astringent and protective dressing for burns, 
acute ulcers , and acute inflammatory skin diseases. Dusting- 
powders containing zinc oxid, starch, and Venetian talc, in 
various proportions, are very serviceable in vesicular eczema 
and in erythema intertrigo. 

R Zinci oxidi, 

Talci purificati, aa £j (4.0 gm.) ; 

Pulveris amyli, £ij (8.0 gm.). — M. 



ARGENTUM. 369 

Internally, zinc oxid has been employed as an antispasmodic 
and an antihydrotic, but it is useless for either of these pur- 
poses. 

ZINCI CARBONAS. 

(Zinc Carbonate; 2ZnC0 3 . 3Zn(OH) 2 .) 

Zinc carbonate is official in the form of precipitated zinc car- 
bonate {Zinci Carbo?ias Prcecipitatus, U. S. P.), which is an 
impalpable white powder, of variable composition, odorless and 
tasteless, and insoluble in ordinary menstrua. 

An impure precipitated carbonate of zinc, known as calamin, 
was formerly official (i860). 

Therapeutics. — Zinc carbonate resembles zinc oxid in 
appearance and in therapeutic properties. It is chiefly employed 
as a sedative and protective application in acute inflammatory 
affections of the skin, such as eczema, erythema intertrigo, and 
dermatitis venenata. It is often combined with zinc oxid, as in 
the following formula : 

R Zinci carbonatis prsecipitati, 

Zinci oxidi, aa £iiss (10.0 gm.) ; 

Glycerini, fsjj (4.0 c.c.) ; 

Liquoris calcis, f^ij (60.0 c.c.) ; 

Aquae rosae, q. s. ad f'^vj (178.0 c.c). — M. 

ZINCI CHLORIDUM, U. S. P. 

(Zinc Chlorid; ZnCl,.) 

Zinc chlorid occurs in white, granular powder or porcelain- 
like masses, or molded pencils, very deliquescent, odorless, 
and of a caustic metallic taste. It is freely soluble in water and 
in alcohol. 

Preparation. 

Liquor Zinci Chloridi, U. S. P. (50 per cent, by weight of zinc chlorid). 

Therapeutics. — Zinc chlorid is the least astringent and the 
most caustic of the zinc salts. At present it is rarely employed 
except as an escharotic in removing superficial epitheliomata. 
Its action is rather slow, and is attended with severe pain. It 
is best applied in the form of a paste, which may be made by 
mixing 1 part of zinc chlorid and 3 parts of flour with a satu- 
rated solution of cocain hydrochlorid. 

The solution of zinc chlorid has an unmerited reputation as a 
disinfectant. 

ARGENTUM. 

(Silver; Ag.) 

The following preparations of silver are official: Silver 
cyanid (Argenti Cyanidum, U. S. P.), silver nitrate {Argenti 

24 



370 ASTRINGENTS. 

Nitras, U. S. P.), and silver oxid (Argenti Oxidutn, U. S. P.). 
Of these, the only one of any importance is silver nitrate. 

ARGENTI NITRAS, U. S. P. 

(Silver Nitrate ; Lunar Caustic ; AgN0 3 .) 

Silver nitrate occurs in colorless, transparent, tabular, rhom- 
bic crystals, odorless, of a caustic metallic taste, and soluble in 
0.54 part of water and in 4 parts of alcohol. It turns dark on 
exposure to light. The dose is from -J— J gr. (0.01-0.03 gm.). 

Preparations. 

Argenti Nitras Fusus, U. S. P. (silver nitrate molded into hard, white 

cones or pencils). 
Argenti Nitras Mitigatus, U. S. P. (mitigated caustic ; molded cones or 

pencils of silver nitrate and potassium nitrate, containing about 33 

per cent, of the former). 

Physiologic Action. — When applied undiluted to the 
skin, silver nitrate acts as a superficial escharotic, producing a 
white slough which subsequently turns black on exposure to 
light. Upon mucous membranes and raw surfaces it acts in 
dilute form as an unirritating astringent, precipitating the 
albumin of the cells with which it comes in contact, and con- 
tracting the blood-vessels ; in concentrated form it acts as a 
caustic, coating the part with a white pellicle of silver albumi- 
nate. Its corrosive action, however, never extends very deeply 
on account of the impenetrable nature of the coagulum that is 
at once formed. 

Silver nitrate is an active germicide, solutions of 1 : 2500 
destroying the organisms of diphtheria, cholera, glanders, and 
typhoid fever in two hours. 

When taken internally in medicinal doses, it exerts no other 
influence than that of an astringent and an antiseptic. Being 
so readily precipitated by chlorids, proteids, and acids, its 
astringent action is chiefly expended on the mucous membrane 
of the stomach. The bulk of it escapes absorption, but that a 
small percentage enters the circulation is evident from the fact 
that the prolonged use of the drug is followed by a deposit of 
silver in the skin and internal organs. Very little is known 
concerning its elimination ; it is supposed to be excreted 
slowly and imperfectly in the urine. 

Toxicology. — In large doses silver nitrate acts as an 
irritant poison, producing intense abdominal pain, persistent 
vomiting and purging, and collapse. White or blackish patches 
may be present on the lips and mucous membrane of the 



ARGENTUM. 371 

mouth. Death is sometimes preceded by delirium, convul- 
sions, and coma. 

Treatment. — Common salt is the best antidote. It forms 
with the poison an insoluble and inert chlorid of silver. De- 
mulcents should also be used freely. 

Argyria. — The long-continued use of silver nitrate, either 
internally or locally, may result in the permanent deposition 
of dark granules of metallic silver in various tissues of the 
body. This pigmentation is known as argyria. Clinically, its 
chief manifestation is a peculiar, bluish-gray discoloration of 
the skin and mucous membranes. In the majority of cases 
there is no impairment of the general health. It is incurable. 

Therapeutics. — At the present time silver nitrate is chiefly 
used for its action on inflamed mucous membranes and ulcerated 
surfaces. In chronic ulcers a solution of from 10 to 40 grains 
to the ounce (0.6-2.6 gm. to 30.0 c.c.) or the solid stick may be 
employed as a stimulant application. Silver nitrate is perhaps 
the best caustic for removing exuberant or superfluous granula- 
tions. Its employment in poisoned wounds, especially in the 
punctured variety, and in those resulting from the bites of 
rabid animals, is to be condemned on account of its superficial 
action and the premature closure of the orifice. A strong 
solution (30 gr. to 1 oz. — 2.0 gm. to 30.0 c.c.) will sometimes 
abort a felon if applied early. In acute epididymitis counter- 
irritation may be secured by drawing a pencil of lunar caustic 
several times over the posterior surface of the scrotum, but 
this treatment is less efficacious than the application of guaia- 
col (p. 286). The treatment of erysipelas by local applications 
of silver nitrate, so highly recommended by Higginbottom, 
has few advocates at the present time. 

In simple conjunctivitis, when the discharge has become 
mucopurulent, the membrane may be painted with a solution 
containing from 3 to 5 grains to the ounce (0.2-0.3 to 30.0 c.c). 
In purulent ophthalmia and ophthalmia neonatorum the con- 
junctiva, after being thoroughly cleansed, may be touched with 
a 10-grain solution (0.65 gm. to 30.0 c.c). Crede's prophylactic 
treatment, which consists in the instillation of 2 drops of a 2 
per cent, solution into the eyes of the new-born child when 
gonorrhea in the mother is suspected, has given excellent 
results. It must be remembered that the long-continued use 
of collyria containing silver nitrate may be followed by perma- 
nent discoloration of the conjunctiva. 

Copious irrigation of the urethra with hot solutions of silver 
nitrate (1 : 10,000) has been found serviceable in both acute and 



372 ASTRINGENTS. 

subacute gonorrhea. Excellent results are obtained in chronic 
cystitis by washing out the bladder first with distilled water and 
then with a solution of silver nitrate (i : 8000). 

Solutions varying in strength from 10 to 60 grains to the 
ounce (0.6-4.0 gm. to 30.0 c.c.) are extensively employed in 
the treatment of chronic stomatitis, chronic pharyngitis, and 
chronic laryngitis. Light touches of the solid stick act very 
favorably upon mucous patches. 

In chronic dysentery great benefit often follows the use of 
copious injections into the bowel of solutions of silver nitrate 
(10-30 grains to the pint — 0.65-2.0 gm. to 0.5 L.). These in- 
jections should be given two or three times a week, the fluid 
being introduced very slowly through a tube passed well up 
into the bowel. At first the amount injected should not ex- 
ceed 2 pints (1.0 L.), but later 4 or 5 pints (2.0-2.5 L.) may be 
employed with advantage. 

Internally, silver nitrate is employed chiefly for its local 
action on the gastro-intestinal tract In chronic gastric catarrh 
and in ulcer of the sto?nach no remedy, with the exception of 
bismuth subnitrate, is so generally useful. In obstinate catarrh 
of the stomach, especially when there is supersecretion or 
marked hyperesthesia of the mucous membrane, douching the 
stomach once or twice a week, first with a solution of silver 
nitrate (1:5000 to 1 : 2000) and then with plain water, is a 
valuable method of treatment. About a pint (0.5 L.) of the 
solution should be introduced through the douche at each 
operation. Silver nitrate is also used in acute and chronic en- 
teritis, but with less benefit than in inflammatory diseases of 
the stomach. 

The treatment of epilepsy, locomotor ataxia, and chorea by 
the administration of the salts of silver possesses little more 
than a historic interest. 

Administration. — In affections of the stomach silver nit- 
rate should be given in pill form, half an hour before meals. 
Powdered opium or extract of hyoscyamus may be used as an 
excipient. When intended to act in the bowel, it should be 
given in keratin-coated pills. The administration of silver 
should not be continued for a longer period than six or 
eight weeks without interrupting the treatment for a like 
period. 

Incompatibles. — Organic matter, bromids, chlorids, iodids, 
cyanids, sulphids, carbonates, phosphates, arsenites, and hydro- 
chloric acid. With creasote it is explosive. 

Organic Silver Salts and Soluble Silver. — Many at- 
tempts have been made recently to produce compounds of sil- 



ARGENTUM. 



373 



ver that will not precipitate albumins and chlorids, and yet will 
retain the germicidal properties of the metal. The most im- 
portant compounds of this class thus far introduced are argen- 
tamin, silver lactate (actol), silver citrate (itrol), protargol, ar- 
gyrol, and largin. In addition to these, Crede has also sug- 
gested a soluble allotropic form of silver (argentum solubile). 
The therapeutic value of these preparations has not yet been 
definitely determined. 

Argentamin. — This is a solution of silver nitrate (10 
per cent.) in an aqueous solution of ethylendiamin (10 per 
cent.), the purpose of the ethylendiamin being to prevent the 
precipitation of the salt by albumins and chlorids. Like other 
silver preparations, it is decomposed by light. It has been 
used chiefly in gonorrhea and in conjunctivitis ; in the former, 
in solutions of from I : 2000 to 1 : 100, and in the latter, in 
solutions of from 3 to 5 per cent. In the eye its action is 
somewhat irritating. 

Silver Lactate (Actol). — This is a white powder, free from 
odor and taste, and soluble in about 20 parts of water. It is a 
powerful germicide, solutions of 1 : 1000 destroying most micro- 
organisms within five minutes. Solutions of from 1 : 1000 to 
I : 500 have been employed for injection in gonorrhea, but they 
have proved very irritating. 

Silver Citrate (Itrol). — This salt resembles the lactate in 
appearance, but as it is almost insoluble in water, it is much 
less irritating. It has been used as an antiseptic dusting- 
powder for wounds, and in solution (1 : 5000) as a disinfectant 
for instruments and the skin. 

Protargol. — This is a proteid compound of silver containing 
about 8 per cent, of metallic silver. It is a fawn-colored 
powder, freely soluble in water. It is an energetic germicide 
and comparatively free from irritant properties. It has been 
used quite extensively and with good results in purulent con- 
junctivitis (1 to 10 per cent, solution), in gonorrhea (0.25 per 
cent, solution gradually increased to 2 per cent.), and in sup- 
purative middle-ear disease (3 to 5 per cent, solutions). 

Argyrol (Silver Vitellin). — This is a compound of silver 
and a vegetable proteid containing 30 per cent, of metallic 
silver. Its high percentage of silver (nearly four times that of 
protargol), extreme solubility, and comparative freedom from 
irritant properties make it one of the most serviceable of the 
organic silver compounds. In solutions of from 5 to 25 per 
cent, it has been used with considerable success in both acute 
and chronic gonorrheal infections, purulent conjunctivitis, and 
suppurative affections of the ear, nose, and throat. 

Largin. — This is also a proteid compound of silver. It is 



374 ASTRINGENTS, 

a grayish powder, freely soluble in water, containing about 1 1 
per cent, of metallic silver. It has been used with asserted 
good results in gonorrhea (0.5 to 1.5 per cent, solution) and in 
purulent ophthalmia (1 to 10 per cent, solution). 

Soluble or Colloidal Silver (Argentum Colloidale, Collar- 
gol). — This is an allotropic form of silver, occurring in heavy, 
greenish-black particles, readily soluble in water, forming a 
reddish-brown solution. It is most commonly used in the 
form of a 15 per cent, ointment, known as Crede's ointment, 
which has been found of service as a local remedy in such con- 
ditions as e?ysipelas, lymphadenitis, septic phlebitis, and go?wr- 
rheal arthritis. With the view of producing a constitutional 
impression, daily inunctions of the ointment (45 gr. — 3.0 gm.) 
have also been employed in various septic processes, but this 
method of using the drug is not very promising. 

BISMUTHUM. 

(Bismuth; Bi.) 

The following preparations of bismuth are official : Bismuth 
subnitrate {Bismuthi Subnitras, U. S. P.), bismuth subcarbonate 
(Bismuthi Subcarbo?ias } U. S. P.), bismuth subgallate {Bismuthi 
Subgallas), bismuth subsalicylate {Bismuthi Subsalicylas), bis- 
muth citrate {Bismuthi Citras, U. S. P.), and bismuth ammo- 
nium nitrate {Bismuthi et Ammonii Citras, U. S. P.). As the 
bismuth preparations are useful largely on account of their 
insolubility, the soluble salts — bismuth citrate and bismuth 
and ammonium citrate — seem to be superfluous. Among 
compounds oi bismuth which are in use, but which are not 
official, may be mentioned tribromphenol-bismuth (xeroform), 
and betanaphthol-bismuth (orphol). These will be considered 
in the section devoted to Germicides and Antiseptics (p. 383). 

BISMUTHI SUBNITRAS, U. S. P. 
(Bismuth Subnitrate; BiON0 3 -(-H 2 0(?).) 

Bismuth subnitrate is a heavy white powder, of a somewhat 
varying composition, odorless, almost tasteless, and permanent 
in the air. It is insoluble in water and in alcohol. The dose 
is from 5-40 gr. (0.3-2.6 gm.). 

Physiologic Action. — When taken internally, even in 
very large doses, the effects of bismuth subnitrate are confined 
to the mucous membrane of the alimentary canal, its action 
being that of a feeble astringent and protective. Since traces 
of the metal have been found in the urine there must be some 
absorption, but the amount of the drug entering the blood 
is undoubtedly too small to exert any special influence. 
Worden, Sailer, and Pancoast have reported six cases in which 



BISMUTHUM. 375 

alarming symptoms were observed after 2 to 4 ounces (60.O- 
120.0 gm.) of perfectly pure bismuth subnitrate had been given 
for diagnostic purposes. It is suggested, however, that the 
symptoms were due to the formation of nitrites in the intestines, 
as they were quite unlike those produced by heavy metals. 
The characteristic black stools following the administration of 
the drug are attributed to its partial conversion into a sulphid 
in the intestine. The breath of patients taking bismuth some- 
times acquires a peculiar garlicky odor ; this is due, as Reisert 
has demonstrated, to the minute tellurium impurities often 
present in commercial bismuth compounds. 

Upon the unbroken skin bismuth subnitrate acts simply as 
a protective, but on raw surfaces it acts also as an astringent 
and antiseptic. Absorption takes place rather readily from 
denuded parts, and poisoning may occur if the drug be applied 
too freely. The symptoms of bismuth poisoning are saliva- 
tion, stomatitis, dysphagia, a black discoloration of the mucous 
membrane of the mouth, ulceration of the throat, diarrhea, 
and albuminuria. 

Therapeutics. — No drug is so generally useful as bismuth 
subnitrate in allaying gastric irritation from various causes. It 
is a standard remedy in both acute and chronic gastric catarrh 
and in gastric ulcer. In the latter affection excellent results 
are often obtained by giving a single daily dose of from 1-2 
dr. (4.0-8.0 gm.) in the morning, on an empty stomach, and then 
having the patient assume various positions — on the back, on 
the right, and on the left side, remaining in each position for 
five or ten minutes. In many cases of ulcer an alkali, such as 
sodium bicarbonate or magnesia, may be added with advantage. 
Even in gastric cancer the drug sometimes affords temporary 
relief. It is of much service in gastralgia dependent upon ex- 
cessive acidity of the stomach. Vomiting the result of gastric 
irritation generally yields to it. It is especially efficacious as 
an antiemetic when conjoined with diluted hydrocyanic acid. 

In catarrhal diarrhea, after the intestine has been thoroughly 
emptied, bismuth subnitrate is invaluable as a protective and an 
astringent. In these cases it may be combined advantageously 
with morphin and an antiseptic, as in the following formula : 

R Morphinae sulphatis, gr. j (0.06 gm.) ; 

Salol, gr. xxx (2.0 gm.); 

Bismuthi subnitratis, ^vj (24.0 gm.). M. 

Fiant chartulae No. xv. 
Sig. One every three hours. 

Topically, bismuth subnitrate, alone or with starch, may be 
used as a dusting-powder in acute erythema and in intertrigo. 
In the form of a paste made with glycerin and water it has 



376 ASTRINGENTS. 

been employed rather extensively also as a protective dressing 
for burns ; in a number of instances, however, such applica- 
tions have been followed by poisoning. In the second stage of 
gonorrhea injections of bismuth subnitrate, 15 gr. (1.0 gm.) to 
the ounce (30.0 c.c.) of glycerin and water, have a favorable 
action. 

In acute coryza a snuff composed of bismuth subnitrate, gum 
acacia, and a little morphin sometimes affords relief. 

Administration. — It is usually prescribed in powders or 
in capsules. Very large doses, however, may be given con- 
veniently in water, the mixture being well shaken before each 
administration. Alkaline bicarbonates and sodium hyposul- 
phite are incompatible with such mixtures. In affections of 
the stomach the drug should be taken half an hour before 
meals. 

BISMUTHI SUBCARBONAS, U. S. P. 

(Bismuth Subcarbonate ; (BiO) 2 C0 3 -f H 2 (?).) 

Bismuth subcarbonate closely resembles bismuth subnitrate 
in its physical properties and action. Its uses and dose are 
the same as those of the subnitrate. When an enormous dose 
of a bismuth salt is required, as in the skiagraphic examination 
of the stomach and intestines, the subcarbonate should be 
selected in preference to the subnitrate, as being less likely to 
cause ill-effects -from decomposition. 

BISMUTHI SUBGALLAS. 

(Bismuth Subgallate; Dermatol; C6H 2 (OH) 3 C0 2 Bi(OH) r ) 

Bismuth subgallate is a fine, yellowish-white powder, odor- 
less and tasteless, permanent, and insoluble in ordinary sol- 
vents. It should contain not less than 52 per cent, nor more 
than 57 per cent., of bismuth oxid. The dose is from 5-30 gr. 
(0.3-2.0 gm.). 

Therapeutics. — Bismuth subgallate has been employed 
somewhat extensively as a protective and an astringent appli- 
cations for burns and moist eczema. It does not appear, how- 
ever, to have been less harmful than other bismuth compounds 
when used externally. Internally it has been used instead of 
the subnitrate in catarrhal affections of the stomach and intestine^ 
but it has no advantages over the official preparation. 

BISMUTHI SUBSALICYLAS, U. S. P. 

(Bismuth Subsalicylate ; Bi(C r H s 3 ) 8 Bi 3 3 .) 

Bismuth subsalicylate is a white amorphous or crystalline 
powder, odorless and tasteless, and insoluble in water. It is 
used chiefly as an intestinal antiseptic and astringent in 
diarrhea. The dose is from 5-20 gr. (0.3-1.3 gm.). 



HEMOSTA TICS. 377 

CALCII CARBONAS. 

(Calcium Carbonate; Chalk ; CaC0 3 .) 

Chalk is official in two forms : Precipitated calcium carbon- 
ate {Calcii Carbonas Prcecipitatus, U. S. P.) and prepared chalk 
{Creta Prceparata, U. S. P.). The dose of either preparation is 
from 10-40 gr. (0.65-2.3 gm.) or more. 

Preparations. Dose. 

Pulvis Cretse Compositus, U. S. P. (prepared 

chalk, 30; acacia, 20; sugar, 50) . . . 5-40 gr. (0.3-2.3 gm.). 
Mistura Cretse, U. S. P. (compound chalk 

powder, 20; cinnamon water, 40; water, 

q. s. 100) 1-4 fl. dr. (4.0-15.0 c.c). 

Hydrargyrum cum Creta, U. S. P. (57 per 

per cent, of chalk) \~ l ° g 1 - (0.03-0.6 gm.). 

Therapeutics. — Chalk is a mild astringent and antacid, 
free from irritant properties. It may be employed in acute 
inflammatory diarrhea in the same manner as bismuth sub- 
nitrate. It is an excellent antacid when acidity of the stomach 
is associated with relaxation of the bowels. It may be pre- 
scribed as an antidote in poisoning by a mineral acid or by 
oxalic acid. 

Externally, it is used as a dusting-powder in erythematous 
eczema and intertrigo. It is particularly useful in the chafing 
of the genitalia and buttocks of young children from irritation 
by urine. It enters into the composition of most tooth-powders. 



HEMOSTATICS. 

Hemostatics are agents that arrest hemorrhage. They all 
act in accordance with the methods pursued by nature in 
spontaneously closing a bleeding vessel. If an artery be 
divided, it shrinks within its sheath, the contiguous structures 
fall in upon the bleeding orifice, and if the hemorrhage be 
copious, the force of the circulation diminishes and the coagula- 
bility of the blood increases. The choice of the hemostatic 
will largely depend upon the seat of the hemorrhage — that is, 
whether it is in an accessible or in an inaccessible region, and 
upon its source — that is, whether it is of capillary, of venous, 
or of arterial origin. Hemorrhage from a large vessel in an 
accessible region should always be controlled by mechanical 
means — that is, by ligature, torsion, pressure, acupressure, or 
cauterization. Many parts formerly considered inaccessible are 



378 HEMOSTA TICS. 

no longer so regarded, and to-day surgical aid is sometimes 
wisely invoked to arrest excessive bleeding from such organs 
as the stomach and bowel, and even the brain. 

Small external hemorrhages, especially capillary oozing, are 
often satisfactorily controlled by the direct application of agents 
that contract the vessels or that coagulate the albumin of the 
blood. The most potent local vasoconstrictors are cold, in the 
form of water or of ice, and adrenalin ; and the most powerful 
styptics are ferric subsulphate, ferric chlorid, alum y and tannic acid. 

Three classes of drugs have been recommended to control 
hemorrhage in organs that must be reached through the cir- 
culation. The first includes drugs like tannic acid and certain 
mineral salts, which have been found useful as local styptics or 
astringents ; the second, drugs like ergot, which cause vaso- 
constriction by stimulating the vasomotor centers or by acting 
directly on the muscular walls of the vessels ; and the third, 
drugs like gelatin and calcium chlorid, which are thought to 
increase the natural coagulability of the blood. 

There is no reason to believe that tannic acid exerts any in- 
fluence as a hemostatic outside of the alimentary canal, since 
it enters the blood in such a form {gallic acid) that it loses its 
styptic and astringent properties. As regards the mineral 
astringents, it is exceedingly doubtful whether any one of them 
can enter the circulation in sufficient quantity to exert a favor- 
able influence upon a hemorrhage in a territory remote from 
the point of absorption. Owing to its power of causing con- 
traction of the unstriped muscle of the uterus, ergot is unques- 
tionably of value in controlling certain forms of metrorrhagia, 
but the testimony to its efficacy in other internal hemorrhages, 
such as hemoptysis and hematuria, is not convincing. Grant- 
ing that it has the power of causing vasoconstriction through 
a central influence, it is unreasonable to suppose that its effects 
are limited to the vessel concerned in the bleeding, and if such 
be not the case, it should tend to do harm rather than good, 
since a universal narrowing of the blood-paths and a conse- 
quent rise in the blood-pressure must favor the escape of blood 
and also hinder the formation of an occluding thrombus. Like 
ergot, hydrastinin and cotarnin also act as vasoconstrictors. 
While clinical experience has shown them to be of value in 
some forms of metrorrhagia, it is doubtful whether they are of 
any avail in bleeding from other organs. Gelatin and calcium 
chlorid have recently been recommended as internal hemo- 
statics on the ground that they increase the normal coagula- 
bility of the blood. The former appears to be more reliable 



HYDRASTIS. 379 

than the latter, but sufficient time has not yet elapsed to allow 
of any decided opinion of its efficacy. 

In the treatment of internal hemorrhage absolute rest of 
body and mind is essential. An ice-bag may be applied over 
the seat of the bleeding. Opium is of great value ; it not only 
exerts a calmative effect, but it also serves to control involun- 
tary movements, such as cough and peristalsis. For the pur- 
pose of lowering the blood-pressure a ligature may be applied 
to a leg or an arm. For the profound anemia which accom- 
panies or follows profuse hemorrhage normal salt solution may 
be given subcutaneously. 

The only drugs employed as hemostatics which have not 
been considered in other sections are hydrastis, cotarnin, gela- 
tin, and calcium chlorid. 

HYDRASTIS, U. S. P. 

(Golden Seal.) 
Hydrastis is the rhizome and root of hydrastis canadensis, 
a perennial herb growing in the woods of North America east 
of the Mississippi. It contains hydrastin, berberin, and canadin. 
Of these hydrastin is official as Hydrastina. By oxidizing 
hydrastin with potassium permanganate the artificial alkaloid 
hydrastinin is obtained, which is official as Hydrastinince Hydro- 
chloridum. The dose of crystalline hydrastin is from \-\ gr. 
(0.01-0.03 gm.); of hydrastinin hydrochlorid, from J-i gr. 
(0.016-0.06 gm.). 

Preparations. Dose. 

Fluidextractum Hydrastis, U. S. P £-1 fl. dr. (2.0-4.0 c.c). 

Tinctura Hydrastis, U. S. P J-2 fl. dr. (2.0-8.0 c.c). 

Glyceritum Hydrastis, U. S. P £-2 fl. dr. (2.0-8.0 c.c). 

Physiologic Action. — Hydrastis owes its activities largely 
to the presence of the alkaloid hydrastin. The latter is first 
an excitant and then a paralyzant of the spinal cord, conse- 
quently toxic doses are followed first by tetanic convulsions 
and later by motor paralysis. Large doses primarily raise the 
blood-pressure by stimulating the vasomotor centers and thus 
constricting the arterioles ; secondarily, they lower the blood- 
pressure by depressing the vasomotor centers and the heart. 
Hydrastin probably increases peristalsis and induces uterine 
contractions, although its power to do the latter has been 
denied by some authorities. Finally, the drug, when locally 
applied, seems to exert a favorable influence on chronic 
catarrhal inflammations, but the manner of its action is not 
understood. 

Hydrastinin in very large doses is a powerful paralyzant to 



3 So HEMOSTA TICS, 

the motor centers of the brain and spinal cord. The paralysis 
is apparently not preceded, as in the case of hydrastin, by a 
stage of motor excitation. Like hydrastin, it raises the arterial 
pressure, but its action in this respect differs from that of 
hydrastin in being more pronounced and more lasting and in 
not being followed secondarily by circulatory depression. The 
rise in the arterial pressure is due in part to stimulation of the 
vasomotor centers, and in part, also, according to some authors, 
to stimulation of the heart and of the muscular coats of the 
arterioles. Whether or not hydrastinin can induce uterine 
contractions is a moot question, but the trend of experimental 
evidence favors the view that it does possess ecbolic properties 
and is capable, in sufficient dose, of causing abortion. 

Therapeutics. — Hydrastis is a useful local remedy in cer- 
tain catarrhal affections. In leukorrhea, injections of the fluid 
extract, 2 fluidrams (8.0 c.c.) to the pint (0.5 L.) of hot water, 
are often beneficial. In the catarrhal stage of gonorrhea injec- 
tions of hydrastinin hydrochlorid, 1-5 gr. (0.06-0.3 gm.) to 
the ounce (30.0 c.c), have been used with excellent results. The 
same preparation, in doses of from y^— J gr. (0.005-0.01 gm.),has 
also been highly recommended as an internal remedy in chronic 
gastric catarrh, especially when there is muscular atony. 

Both hydrastinin and hydrastin have been largely used in- 
ternally as uterine hemostatics. They are particularly effi- 
cacious in menorrhagia or metrorrhagia dependent upon con- 
stitutional disorders, endometritis, or disease of the adnexa. 

Hydrastin cannot be used externally owing to its insolu- 
bility. 

COTARNIN^E HYDROCHLORID. 

(Stypticin.) 

Cotarnin is an artificial alkaloid closely allied to hydrastinin 
in its chemical composition, and obtained by the oxidation of 
the opium alkaloid, narcotin. It appears in the form of yellow 
crystals of a bitter taste, and freely soluble in water. The 
dose is from f-3 gr. (0.3-0.2 gm.), three or four times a day. 
It may be administered by the mouth or subcutaneously. Its 
action resembles that of hydrastinin, but is less rapid. It has 
been found useful as a hemostatic in uterine hemon'hages not 
accompanied by gross lesion of the uterine mucous membrane. 

GELATINUM, U. S. P. 

(Gelatin.) 

Gelatin is the air-dried product of the action of boiling 
water on gelatinous animal tissues, such as skin, tendons, liga- 
ments, and bones. It occurs in brittle, transparent sheets or 
shreds, without odor or taste. It is insoluble in cold water, 



GELATINUM. 38 1 

but freely so in hot water, and if the solution contain more 
than 2 per cent., it solidifies on cooling. Solutions heated 
above a temperature of 230 F. (no° C), however, remain 
permanently liquid. 

Physiologic Action. — In 1896 Dastre and Floresco 
demonstrated that blood drawn from a dog into which a 5 per 
cent, solution of gelatin had been injected intravenously solidi- 
fied almost immediately, and further that the same result could 
be secured by adding gelatin to the blood outside of the body. 
That the solidification was due to clotting and not merely to 
jellifying was evident from the fact that it occurred at a tem- 
perature (3 8° C.) at which a 5 per cent, solution of gelatin will 
not jellify, and, moreover, that it occurred also with solutions 
containing a percentage of gelatin much under that which is 
necessary for jellying — that is, under 2 per cent. These ob- 
servers also showed that gelatin could offset the anticoagulant 
action of peptones, but not of concentrated saline solutions or 
of substances which decalcify the blood, like oxalic acid. In 
1898 Lancereaux and Paulesco found that subcutaneous in- 
jections of gelatin were quite as efficient in increasing the 
coagulability of the blood as intravenous injections. Whether 
or not its power is affected by digestion has not been defi- 
nitely determined, although a number of practitioners have 
attributed good results in hemorrhage to its administration 
by the mouth or rectum. No satisfactory explanation has yet 
been offered of the action of gelatin in promoting the coagula- 
bility of the blood. 

Therapeutics. — Carnot appears to have been the first to 
bring gelatin prominently forward as a hemostatic ; although, 
according to Miwa, it has been used for this purpose for many 
centuries in Oriental countries. Considerable testimony has 
already accumulated as to its efficacy in hemorrhages from 
both external and internal parts. As a local remedy it has 
been used with success in epistaxis, metrorrhagia, bleeding front 
hemorrhoids, and in oozing from wounds. As an internal hemo- 
static it has apparently rendered service in hemoptysis, hema- 
turia, and enter orrhagia. It has been found efficacious also in 
hemophilia, purpura hemorrhagica, and melcena neonatorum. 
For bleeding in accessible parts a 10 per cent, solution may be 
applied on tampons. The solution should be sterilized and should 
have added to it a small quantity of carbolic acid to prevent de- 
composition. The dose for subcutaneous administration is from 
15—45 % x > (1.0-3.0 gm.), in the form of a 5 or 10 per cent, solu- 
tion, once or twice a day. The best vehicle is normal salt 
solution. A 10 per cent, solution may be prepared by dissolv- 
ing 1 J ounces (50.0 gm.) of gelatin and 35 gr. (2.5 gm.) of 



382 HEMOSTA TICS. 

salt in a pint (0.5 L.) of hot distilled water. After the mixture 
has been allowed to cool, the white of an egg should be stirred 
in, and the whole brought quickly to the boiling-point. The 
mixture should next be filtered first through gauze and then 
through paper. Finally, it should be poured into small flasks 
and sterilized in a steam sterilizer, fifteen or twenty minutes, 
once daily, for three days. Prepared in this way the mixture 
will keep for several weeks. When required, it should be 
liquefied by standing the flask in hot water, and then injected 
to the amount of from 3 to 5 fluidrams (10.0-20.0 c.c.) into the 
thigh or under the breast, using for the purpose a perfectly 
sterile syringe. When the fluid is free from turbidity, the in- 
jections are not painful. It is exceedingly important that the 
solution should be absolutely sterile, since commercial gelatin 
not infrequently contains tetanus bacilli. Several cases of 
tetanus developing after gelatin injections have recently been 
reported. Acute nephritis is regarded by some authorities as 
a contraindication to the employment of gelatin subcutaneously. 

When administered by the mouth, it may be given in doses 
of from 1-8 dr. (4.0-30.0 gm.) or more daily. 

The treatment of aortic aneurysms by subcutaneous injec- 
tions of gelatin, first recommended by Lancereaux, although 
it seemed promising, has not proved very satisfactory. It is 
followed, however, in a certain proportion of cases by a tem- 
porary amelioration of the symptoms. It is credited with hav- 
ing caused embolism in one or two instances. 

Gelatin makes a good protective dressing for indolent leg 
ulcers, especially when they are accompanied by chronic 
eczema. It may be employed in the form of Unna's dressing : 

JJ Zinci oxidi, 

Gelatini, aa 3J (4.0 gm.); 

Glycerini, 

Aquae, aa fj^iv (120.0 c.c). M. 

Sig. After the ulcer has been thoroughly cleansed and disinfected, 
coat the eczematous regions with Lassar's paste (starch and zinc 
oxid, of each, 2 parts; vaselin, 4 parts), dust the ulcer with 
iodoform, and cover it with cotton. Then paint the entire limb 
with Unna's dressing melted and applied with a brush. Band- 
age evenly and firmly, first with gauze soaked in hot water, then 
with dry gauze, and finally with a cotton roller bandage. The 
dressing should be changed every two, four, or six days, accord- 
ing to the amount of discharge. 

Incompatible s. — Tannic acid and formaldehyd. 



GERMICIDES, ANTISEPTICS, AND DEODORIZERS. 383 

CALCII CHLORIDUM, U. S. P., and CALCII 
LACTAS. 

(Calcium Chlorid, CaCl 2 , and Calcium Lactate, Ca(C 2 H 4 OH.COO) 2 + 5H 2 0.) 

Calcium chlorid occurs in white, slightly translucent, hard 
fragments, very deliquescent, odorless, and of a sharp saline 
taste. It is soluble in 1.3 parts of water and in 8 parts of alco- 
hol. Calcium lactate is a white crystalline powder, not readily 
soluble in water unless freshly prepared. The dose of either 
salt is from 5-20 gr. (0.3-1.3 gm.) after meals, well diluted. 

Therapeutics.— The conclusions of Wright, of Netley, 
England, that calcium salts possess the power of increasing 
the coagulability of the blood, have led to their extensive use 
in the treatment of hemophilia, purpura, aortic aneurysjn, and 
various internal hemorrhages, as well as of a number of con- 
ditions, such as urticaria, chilblains, and certain persistent 
headaches, in which blood coagulability is supposed to be 
defective. Recent observers, however, have failed to confirm 
Wright's conclusions, and it is very doubtful if calcium can be 
of benefit in any of the conditions mentioned. Very recently 
MacCallum and Voegtlin have shown that the intravenous in- 
jection of a 5 per cent, solution of calcium lactate causes an 
almost instant arrest of the tetanoid symptoms occurring after 
parathyroidectomy, and believe that the drug may have some 
therapeutic importance, not only in postoperative tetany but also 
in those forms occurring spontaneously. 



GERMICIDES, ANTISEPTICS, AND 
DEODORIZERS. 

Germicides or disinfectants are agents that destroy 
micro-organisms and their spores. They may act by exerting 
some specific influence on the micro-organisms, by coagulating 
their albuminous constituents, or by entering into chemical 
combination with the microprotein. The chief germicides are : 

Mercuric chlorid. 

Phenol (carbolic acid), 



Cresols, 
Creosol, 
Guaiacol, 
Resorcin, 
Naphthalen, 
Betanaphthol, 
Salicylic acid, 
Benzoic acid, 



Aromatic Series. 

> Benzene derivatives or coal- 
tar germicides. 



384 GERMICIDES, ANTISEPTICS, AND DEODORIZERS. 

Formaldehyd. Sulphurous acid. 

Urotropin. Hydrogen dioxid. 

Silver compounds. Potassium permanganate. 

Chlorin. Lime. 
Bromin. 

The various preparations of quinin also possess a moderate 
amount of germicidal power ; they are especially destructive 
to certain protozoa, such as the hematozoa of malaria and the 
amoebae of dysentery. 

Heat is the most certain disinfectant. All known pathogenic 
bacteria and their spores are destroyed by boiling water in 
from five to ten minutes, and by steam (21 2° F. — ioo°C), at 
ordinary pressure, within an hour. Steam under pressure is a 
still more energetic disinfectant. Dry heat, on account of 
slight penetrating power, is much less effective than moist 
heat. According to Koch, sporeless bacteria are destroyed in 
one and one-half hours by hot air at a temperature slightly 
above 21 2° F. (ioo° C), and spores of bacilli in three hours 
by hot air at a temperature of 316 F. (140 C). 

Antiseptics are agents that prevent or hinder the growth 
of micro-organisms without necessarily destroying them. 
Whether a substance act as a germicide or as an antiseptic 
depends largely upon the degree of concentration in which it 
is employed. By dilution germicides may be reduced to the 
rank of antiseptics. The following substances may be classed 
as antiseptics, since in the solutions ordinarily used they ar- 
rest the development of bacteria, but do not destroy them : 

Boric acid. 
Picric acid. 
Ferrous sulphate. 

(Eucalyptus. 
Thyme. 
Sandalwood. 
Copaiba. 
Cubeb. 

r Methyl-blue. 
Many anilin derivatives. < Methylene-blue. 

( Acetanilid. 

Iodoform (see p. 319), although it is practically without 
antiseptic power, nevertheless makes a valuable dressing for in- 
fected wounds. It probably acts indirectly by absorbing 
moisture, by liberating iodin, which is antiseptic, and, perhaps, 
by neutralizing the toxins formed by pyogenic bacteria. 



DEODORIZERS. 385 

Deodorisers are agents that destroy offensive odors. They 
do not, of necessity, possess either germicidal or antiseptic 
power. They may act by oxidizing or deoxidizing fetid com- 
pounds or by abstracting hydrogen from them. The most 
powerful deodorizers are : 

Chlorin. Sulphurous acid. 

Formaldehyd. Potassium permanganate. 

Lime. Hydrogen dioxid. 

Charcoal. 

Pulverized dry earth is a useful deodorant of fecal matter, 
but it is not to be considered as a disinfectant. 

General Surgical Antisepsis. — Mercuric chlorid (see p. 327) 
is the most popular of the germicides for general surgical 
work. It is energetic, soluble, and cheap. On the other 
hand, it has three disadvantages : it is very poisonous, it is de- 
structive to metal instruments, and it is readily converted into 
an inert compound in the presence of albuminous matters. 
This last drawback may be offset by adding to its solutions a 
weak acid (tartaric acid). For the patient's skin and the sur- 
geon's hands solutions of from 1 : 1000 to 1 : 500 should be 
employed; for large wounds and cavities, I : 10,000 to I : 5000; 
and for small wounds, 1 : 2000. On account of its irritant 
properties it should not be used on serous membranes. 

Carbolic acid is not nearly so reliable as corrosive sublimate, 
but it is quite destructive to pus-organisms. It is readily solu- 
ble, is not affected by albuminous matters, and does not seri- 
ously injure metal instruments, although it dulls them. On 
the other hand, it is decidedly toxic, and it has a benumbing 
effect on the hands of the operator. A solution of 1 : 20 is 
often employed for cleansing suppurating wounds, sinuses, and 
abscess cavities. A solution of 1 : 40 is sometimes used as a 
bath for instruments. 

Formaldehyd is a very powerful germicide, but it is too 
irritating to be generally useful in surgical work. One or 2 
per cent solutions of formalin (40 per cent, solution of the 
gas in water), however, are sometimes employed to disinfect 
wounds and to irrigate sinuses and suppurating cavities. In- 
struments may be disinfected by immersion in a 2 per cent, 
solution of formalin, or, better, by subjecting them to the action 
of the gas in a closed chamber (see p. 403). 

Disinfection of the Hands. — Furb ringer's method, or some 
modification of it, is usually followed : after removing all dirt 
from around and beneath the nails, the forearms, hands, and 

25 



386 GERMICIDES, ANTISEPTICS, AND DEODORIZERS. 

nails are thoroughly scrubbed with soap and hot water. The 
hands are then soaked for at least a minute in alcohol (95 per 
cent), and before the alcohol has evaporated they are plunged 
in a hot solution of corrosive sublimate, 1 : 500. Finally, they 
are rinsed in sterile water and dried. The alcohol removes the 
soap and grease from the furrows and pores, and favors the 
penetration of the germicide. Kelly, after scrubbing the hands, 
dips them in a warm, saturated solution of potassium perman- 
ganate, then in a warm, saturated solution of oxalic acid, and, 
finally, in distilled water. Weir's method has been found very 
satisfactory. It is applied as follows : Scrub the hands and 
forearms in running hot water, using a brush and green soap ; 
clean under and around the nails with a bit of soft wood ; 
place in the palm a tablespoonful of chlorinated lime and an 
equal quantity of washing soda (not sodium bicarbonate) ; add 
enough sterile water to make a creamy mass, and rub this 
cream over the hands and forearms until the harsh soda gran- 
ules can no longer be felt. This rubbing should occupy about 
five minutes. Push the paste under and around the nails by 
means of a piece of sterile orange-wood, and then wash in hot, 
sterile water. 

Antisepsis of Mucous Membranes. — The most important bac- 
terial poisons for use on mucous membranes are mercuric 
chlorid, silver nitrate, organic silver compounds, boric acid, 
potassium permanganate, and formalin. 

G astro-intestinal Antisepsis. — Internally, antiseptics are of 
service in controlling fermentation and putrefaction in the con- 
tents of the stomach and bowel. Of course they cannot render 
the alimentary canal aseptic, nor can they affect bacteria like 
the typhoid bacillus and the tubercle bacillus, which multiply 
in the intestinal walls. The chief gastro-intestinal antiseptics 
are carbolic acid, creosote, guaiacol, naphthalin derivatives, 
salicylic compounds, sulphites, resorcin, and thymol. Silver 
nitrate and the mercurial preparations also owe, no doubt, 
some of their efficacy in affections of the digestive tract to their 
antiseptic properties. 

Urinary Antiseptics. — It is quite possible to inhibit the 
growth of micro-organisms in the urine by administering anti- 
septic agents by the mouth. Urotropin, salicylic compounds, 
benzoic acid, and several volatile oils (copaiba, cubeb, sandal- 
wood) are used for this purpose. 

Disinfection of Stools and Sputum. — Stools should be thor- 
oughly mixed with twice their volume of a 1 per cent, chlor- 
inated lime solution, of a 5 per cent, carbolic acid solution, or 
of a 2 per cent, formalin solution, allowed to stand for two or 
three hours, and then buried or discharged into the closet. 



PHENOL. 387 

Infected sputum should be received into cups containing a I 
per cent, chlorinated lime solution or a 5 per cent, carbolic acid 
solution ; or the patient may expectorate into moist rags or 
into impermeable paste-board cups, which should be burnt be- 
fore the sputum has had time to dry. 

Disinfection of Rooms and their Contents. — Articles of little 
value should be burnt. Bedding, clothing, carpets, etc., should 
be disinfected by steam. Towels, napkins, and sheeting should 
be soaked in a 5 per cent, carbolic acid solution and then 
boiled. Woodwork, floors, and plain furniture should be 
washed with a chlorinated lime solution (1 per cent.) or with a 
corrosive sublimate solution (1 : 5000). Finally, the room 
should be fumigated with formaldehyd gas (see p. 4°3) or 
with sulphur dioxid (see p. 407), preferably with the former. 



PHENOL, U. S. P. 

(Phenol ; Carbolic Acid ; C 6 H 5 OH.) 

Phenol or carbolic acid is obtained from the distillation of 
coal-tar, and when pure occurs in the form of colorless, needle- 
shaped crystals of a characteristic odor and of an acrid, burning 
taste. In the light it acquires a reddish tint, and on exposure 
to the air it deliquesces. It is soluble in 19.6 parts of water, 
and freely in alcohol, glycerin, chloroform, ether, and oils. 
Although it combines with salifiable bases, it is chemically not 
an acid, but an alcohol of the benzene group. The dose is 
from \-2 gr. (0.03-0.13 gm.). 

Preparations. Dose. 

Phenol Liquefactum, U. S. P. (86.4 per cent. 

of absolute phenol and 13.6 per cent, of 

water) \-2. min. (0.03-0. 12 c.c). 

Unguentum Phenolis, U. S. P. (3 per cent.). 

Glyceritum Phenolis, U. S. P. (20 per cent.) . 2-10 min. (0.12-0.6 c.c). 

Physiologic Action. — When applied to the skin, carbolic 
acid blanches the surface and causes a burning sensation, which 
is soon followed by numbness. Later the part becomes red 
and then brown, and the epidermis desquamates. On account 
of the albuminous coagulum that it forms its caustic action 
does not extend very deeply into the tissues. Its prolonged 
application, however, even in dilute solution (5 per cent.), has 
been followed by gangrene in a number of instances. Absorp- 
tion readily occurs from cutaneous surfaces, mucous mem- 
branes, and wounds. 



388 GERMICIDES, ANTISEPTICS, AND DEODORIZERS. 

The heart-beat is first slightly quickened and then slowed, 
probably as a result of the direct action of the drug on the 
cardiac muscle. 

Circulatory System. — In poisoning there is a marked fall 
in the blood-pressure from depression of the heart and the 
vasomotor centers. 

Nervous System. — Toxic doses are quickly followed by 
stupor and coma, the result of cerebral depression. In man, 
symptoms referable to the action of the drug on the spinal 
cord are rarely noted, but in the lower animals tetanic seizures 
often develop and are followed by paralysis, indicating that the 
spinal centers are at first excited and then depressed. Locally, 
the drug acts as an anesthetic by paralyzing the peripheral 
sensory nerve filaments. 

Respiratory System. — The respirations are first quickened 
and then slowed, in consequence, probably, of the primary 
stimulation and the secondary paralysis of the respiratory cen- 
ter. In fatal poisoning death usually results from asphyxia. 

Temperature. — Large doses lower the bodily temperature, 
probably through a central action, which results in increased 
heat-dissipation. 

Elimination. — Carbolic acid is eliminated by all the emunc- 
tories, but chiefly by the kidneys. In the tissues a part com- 
bines with sulphuric and glycuronic acids, and is eliminated as 
the double sulphate and glycuronate of phenol ; a part is oxi- 
dized into hydroquinon and pyrocatechin, which leave the 
body also largely as double sulphates and glycuronates. 
When the amount of phenol ingested has been very large, a 
part is excreted unchanged. After large doses the urine 
acquires a smoky or greenish-black color, which is due, prob- 
ably, to oxidation products of hydroquinon and pyrocatechin. 
In poisoning ischuria and albuminuria are common symptoms. 

Action on I/Ower Organisms. — Phenol is fatal to most 
pathogenic bacteria, but is not very effective against spores. 
A solution of I : iooo prevents the development of most 
bacteria ; a solution of I : ioo, under favorable conditions, 
destroys pyogenic cocci, tubercle bacilli, cholera bacilli, and 
many other non-spore-forming bacteria. Anthrax bacilli in 
the spore stage resist the action of a 5 : 100 solution for many 
days. Alcohol and ether as solvents lessen its germicidal 
power, and oils practically destroy it. Heat increases its 
destructive action. 

Toxicology. — Poisoning may result either from the inges- 
tion of the drug or from its external application. After the 
ingestion of a very large dose (1 oz. — 30.0 c.c.) the usual 
symptoms are unconsciousness, contraction of the pupils, ster- 



PHENOL. 389 

torous breathing, a rapid, feeble pulse, and collapse. If the 
dose has not been so large, these symptoms may be preceded 
by those of gastro-enteritis. The characteristic phenomena 
are the odor on the breath, the white, corrugated patches on 
the buccal mucous membrane, and the smoky urine. In 
poisoning from the use of the acid externally the initial symp- 
toms generally are discoloration of the urine, headache, ver- 
tigo, pallor, and muscular weakness. 

Treatment. — Two drugs are of special value when the 
poison has been taken by the mouth : Alcohol, which neu- 
tralizes its caustic action, and a soluble sulphate (Epsom salt), 
which forms with it an innocuous sulphocarbolate. Two or 
three ounces (60.0-90.0 c.c.) of diluted alcohol should be 
poured into the stomach through a tube, and then lavage 
practised with water containing Epsom salt. Demulcents are 
useful in allaying the irritation. The application of external 
heat and the subcutaneous administration of diffusible stimu- 
lants are also indicated. 

Therapeutics. — As an antiseptic . for general surgical pur- 
poses carbolic acid no longer holds a prominent place. Solu- 
tions that are really effective are too irritant and too toxic to 
be employed. It is rarely used at present even for disinfecting 
instruments, because it dulls them and at the same time be- 
numbs the surgeon's fingers. Its prolonged application in the 
form of a moist dressing, even in weak solution, is dangerous. 
Harrington has collected 132 cases of gangrene of the fingers 
or toes from its external application. In most of these cases the 
strength of solution was less than 5 per cent. A solution of 
I : 20 is still employed to some extent for cleansing suppurating 
wounds and abscess cavities. Carbuncles are sometimes aborted 
by injecting into them in the early stage from 5-10 min. (0.3-0.6 
c.c.) of a 10 per cent, solution. Excellent results have been ob- 
tained in anthrax from the injection of from \-\ dr. (2.0-4.0 gm.) 
of the pure acid into and around the eschar in the course of a 
day. Bacelli speaks very favorably of carbolic acid injections 
in tetanus. He recommends that from -|— § gr. (0.02-0.04 gm.) 
should be given hypodermically every two or three hours 
until a daily amount of from 8-15 gr. (0.5-1.0 gm.) has been 
reached. Pure carbolic acid is sometimes employed to destroy 
chancroids and venereal warts and to purify sloughing wounds. 

A 5 per cent, solution may be used for disinfecting soiled 
clothing and various excretions, like sputum, feces, and vomited 
matters. In the form of a 2 per cent, spray it may be employed 
as an inhalation to destroy the fetor of the breath in such 
affections as bronchiectasis and gangrene of the lung. 



390 GERMICIDES, ANTISEPTICS, AND DEODORIZERS. 

Carbolic is very useful as a local sedative and antipruritic. 
Carbolized oil, 10 gr. (0.6 gm.) to the ounce (30.0 c.c), although 
it has no antiseptic power, makes a soothing dressing for super- 
ficial burns. In the form of a lotion it is the most valuable 
remedy we possess to allay itching in eczema, urticaria, jaun- 
dice, and pruritus. It may be employed in the strength of from 
2-3 dr. (8.0-12.0 gm.) to the pint (0.5 L.), as in the following 
formula : 

R Phenolis, £ij-iij (8.0-12.0 gm.) ; 

Acidi borici, Ziv (15.0 gm.) ; 

Alcoholis, f J5J (30.0 c.c.) ; 

Glycerini, f t ^ss (15.0 c.c.) ; 

Aquae, q. s. ad Oj (0.5 L.). M. 

Internally, carbolic acid is used as an antiemetic and as an 
antiseptic. Doses of from 1-2 min. (0.06-0.12 c.c.) are some- 
times efficacious in checking vomiting the result of gastric 
irritability. In the same doses, combined with bismuth, it is 
of service as an antiseptic in flatulent dyspepsia and in acute 
diarrhea. 

Administration. — It may be prescribed in pills, in cap- 
sules, in powders of bismuth subnitrate, or dissolved in some 
aromatic water. 

Incompatibles. — Alkalis, metallic salts, soluble sulphates, 
collodion. 

Sodium Sulphocarbolate, or Sodium Phenolsulpho- 
nate (Sodii Phenolsulphonas, U. S. P.). — This salt occurs in 
colorless, rhombic crystals, odorless, of a saline taste, and 
freely soluble in water. The dose is from 5-20 gr. (0.3-1.3 
gm.). It is much less poisonous than carbolic acid. It is 
sometimes of service as an antiseptic in flatulent dyspepsia and 
in diarrhea. When intended to act in the stomach, it may be 
prescribed in solution ; when intended to act in the intestine, 
in keratin-coated pills. 

£inc Sulphocarbolate, or £inc Phenolsulphonate 
(Zinci Phenolsulphonas, U. S. P.). — This salt is somewhat more 
astringent than sodium sulphocarbolate. A solution of 5 gr. 
(0.3 gm.) to the ounce (30.0 c.c.) is sometimes used as a spray in 
catarrhal affections of the throat and as an injection in the second 
stage of gonorrhea. Internally it often acts favorably in diar- 
rhea. As an intestinal antiseptic the dose is from 2-3 gr. 
(0.1-0.2 gm.) in keratin-coated pills. 

Sosoiodol (Sozoiodolic Acid). — This compound is para- 
phenol-sulphonic acid with 2 atoms of hydrogen displaced by 
2 of iodin. Paraphenol-sulphonic acid is prepared by acting 
on phenol with sulphuric acid in the presence of heat. Sozo- 
iodol occurs in needle-shaped crystals, soluble in water and in 
alcohol. It has been used as a substitute for iodoform. Its 



CRESOLS, CREOSOL, AND GUAIACOL. 39 1 

salts — mercury, potassium, sodium, and zinc — have also been 
employed to some extent as antiseptics. 

Nosophen (Tetra-iodo-phenol-phthalein). — This compound 
is prepared by the action of iodin on a solution of phenol- 
phthalein. It is a pale, yellow, inodorous, and tasteless pow- 
der. With bases it forms salts, the most important of which is 
the sodium salt (antinosin). It is recommended as an antisep- 
tic dusting-powder. 

Xerofotin (Tribromphenol-bismutJi). — This is a yellowish, 
odorless, tasteless, and insoluble powder, representing about 50 
per cent, of bismuth oxid. It has been used in place of iodo- 
form as an antiseptic application for infected wounds, burns, 
etc. 

CRESOLS, CREOSOL, AND GUAIACOL. 

Cresols, of which there are three, — metacresol, orthocresol, 
and paracresol, — are homologues of phenol. They are ob- 
tained from coal-tar by fractional distillation, and are present 
in large quantity in crude carbolic acid. They closely resem- 
ble phenol in their action, and, like the latter, they possess 
distinct germicidal properties. Their slight solubility in water 
is an important disadvantage. They are used chiefly for dis- 
infecting specific excreta. 

Under the name of cresol the U. S. Pharmacopoeia recognizes 
a mixture of the three isomeric cresols obtained from coal-tar, 
and freed from phenol, hydrocarbons, and water. This prepa- 
ration is a colorless or straw-colored liquid, having a creasote- 
like odor, and turning yellowish-brown on exposure to light. 
It is soluble in 60 parts of water, and miscible in all propor- 
tions with alcohol, ether, benzin, and glycerin. Its germicidal 
power is nearly three times greater than that of carbolic acid. 
A 1 per cent, solution may be employed in surgical work for 
the same purposes as carbolic acid. De Schweinitz recom- 
mends a 1 : 1000 solution as a solvent for atropin, cocain, and 
eserin in ophthalmic practice. Such solutions remain free from 
bacteria and are not irritant to the eye. 

Liquor Cresolis Compositus, U. S. P. — This is a linseed-oil 
soap solution of cresol, of 50 per cent, strength. Aqueous 
mixtures containing from 3 to 5 per cent, of this official solu- 
tion may be employed with advantage for disinfecting excreta. 
Mixtures of from 1 to 2 per cent, have been used rather ex- 
tensively in obstetric practice. Injections containing from 0.5 
to I per cent, have been found efficacious in chronic cystitis. 

Creolin is the trade name of an emulsion of cresols prepared 
by means of rosin soap. It is a brownish, syrupy liquid, 
which, diluted with water, forms an opaque mixture. 



392 GERMICIDES, ANTISEPTICS, AND DEODORIZERS. 

Lysol is a cresol preparation made by dissolving in fat, 
and subsequently saponifying with alcohol that portion of 
tar-oil which boils between 374 and 392 F. (190 and 200 
C). It is a brown, oily liquid, with the odor of creosote. It 
contains about 50 per cent, of cresols, and mixes with water to 
form a clear, saponaceous, frothy liquid. It may be used for 
the same purposes as the compound solution of cresol. 

While the cresol preparations are comparatively safe, they 
are not altogether harmless. Poisoning from their absorption 
has not been very rare. There are at least 20 cases of poison- 
ing by lysol on record. 

Creosol and guaiaeol are the chief constituents of creo- 
sote (see pp. 283 and 286). 

THYMOL, U. S. P. 

(Thymic Acid; C 10 H 14 O.) 

Thymol is a homologue of phenol obtained from the oil of 
thyme {Thymus vulgaris) and certain other volatile oils. It 
appears in the form of large, colorless crystals having the odor 
of thyme and an aromatic pungent taste. It is only sparingly 
soluble in water, but freely so in alcohol, ether, and oils. The 
dose is from 1-10 gr. (0.06-0.6 gm.). 

Preparation. Dose. 

Liquor Antisepticus, U. S. P. (contains 0.1 per 

cent, of thymol) . . . \- 2 fi. dr. (2.0-8.0 c.c.). 

Physiologic Action and Therapeutics. — Thymol re- 
sembles carbolic acid in its action, although it is decidedly less 
toxic and less irritant. It has been used as an antiseptic in the 
dressing of wounds, but its aromatic odor soon becomes dis- 
agreeable to the patient, and, moreover, is apt to attract flies. 
A solution of a grain (0.06 gm.) to the ounce of water (30.0 
c.c), a little alcohol being used as a solvent, makes a good 
mouth-wash in the infectious forms of stomatitis and pharyn- 
gitis. An ointment of thymol, 5-30 gr. (0.3-2.0 gm.) to the 
ounce (30.0 gm.), has been used with some success by Crocker 
and others in chronic eczema and psoriasis. The drug makes 
an excellent lotion in senile pruritus. 

Internally, thymol is sometimes used as an antiseptic in sub- 
acute diarrhea. In doses of 30 grains (2.0 gm.) for adults, or 
8-15 grains (0.5-1.0 gm.) for children, repeated in two hours, 
it is the best remedy known for uncinariasis or hook-worm 
disease. It has also been used to some extent as a vermifuge 
against the tapeworm and lumbricoid worm. Thymol may 
be administered in wafers, capsules, or pills. 

Thymolis Iodidum, U. S. P. — This compound, which is 
also known as aristol, is chemically dithymol-diodid. It is 



RESORCINOL. 393 

prepared by acting upon thymol in alkaline solution with 
iodin dissolved in potassium iodid. It is an unstable prepara- 
tion, containing about 45 per cent, of iodin, and appears as a 
brownish-red powder, tasteless and almost odorless. It is 
employed as a substitute for iodoform. Although it has ad- 
vantages over the latter in being odorless and less toxic, it is 
generally not so efficacious. 

RESORCINOL, U. S. P. 

(Resorcin; Metadioxybenzol ; C 6 H 4 (OH) 2 .) 

Resorcin is a diatomic phenol, occurring in the form of 
colorless or faintly reddish prisms or needles having a slightly 
urinous odor and a sweetish, pungent taste. It is readily solu- 
ble in water, alcohol, ether, or glycerin. The dose is from 1-5 
gr. (0.06-0.3 gm.). 

Physiologic Action and Therapeutics. — Resorcin acts 
much like carbolic acid, but it is less poisonous and less irritant. 
Toxic doses produce vertigo, ringing in the ears, tremors, epi- 
leptiform convulsions, quickening of the pulse and respiration, 
unconsciousness, and collapse. The urine becomes of an 
olive-green color. In health it exerts but little effect on the 
temperature, but in the febrile state it causes a marked fall, 
which is accompanied by free perspiration. 

At the present time resorcin is chiefly employed externally 
except in certain diseases of the skin. It is a valuable remedy 
in seborrhea, especially in dandruff, in which disease it may be 
employed in the form of a 3 to 5 per cent, lotion, as in the fol- 
lowing formula : 

R Resorcinolis, ^iss (6.0 gm.) ; 

Olei ricini, TTlxx-xxx ( 1. 2-2.0 c.c.) ; 

Spiritus myrciae, q. s. ad f^iv (120.0 c.c). M. 

A lotion containing from 5 to 20 gr. (0.3-1.3 gm.) to the 
ounce (30.0 c.c.) is often serviceable in subacute and chronic 
eczema, especially of the vesicular variety. It is also a useful 
antipruritic remedy. According to Hartzell, its power to re- 
lieve itching is increased considerably by the addition of 0.5 
per cent, of sodium chlorid to the solution, as in the following 
formula : 

R Resorcinolis, gr. xv-xxx (1.0-2.0 gm.); 

Sodii chloridi, gr. xv (1.0 gm.) ; 

Glycerini, fzjj (8.0 c.c); 

Liquoris calcis, q. s. ad f§iv (120.0 c.c). M. 

Internally, resorcin is occasionally used as an antiseptic in 
chronic diseases of the stomach and in diarrhea. It should be 
given in pill or capsule. 



394 GERMICIDES, ANTISEPTICS, AND DEODORIZERS. 
ACIDUM PICRICUM. 

(Picric Acid; Carbazotic Acid; Trinitrophenol ; C 6 H 2 (N0 2 ) 3 . OH.) 

Picric acid is the product of the action of nitric acid on 
phenol-sulphonic acid, which is obtained by dissolving crystal- 
lized carbolic acid in sulphuric acid. It occurs in yellow, flat 
crystals, odorless, and of an intensely bitter taste. It is spar- 
ingly soluble in water, but freely so in alcohol and in ether. 

Physiologic Action and Therapeutics. — Locally, pic- 
ric acid in pure form acts as a caustic. Poisonous doses pro- 
duce vomiting, diarrhea, yellowness of the skin, mucous mem- 
branes, and urine, convulsions, and collapse. It is a feeble 
bactericide. 

Gauze wet with a I per cent, solution of picric acid, cov- 
ered with cotton, makes an excellent dressing for burns of 
the first and second degree. For fear of poisoning, how- 
ever, the drug should not be applied over large or deep 
burns. A I per cent, lotion has also been found serviceable 
in acute eczema and in herpes zoster. Occasionally local appli- 
cations are followed by an erythematous rash. Injections of 
picric acid, i : 200 to 1 : 100, are recommended by some sur- 
geons in the treatment of the second stage of gonorrhea. A 
saturated solution makes a delicate test for albumin in the urine. 

Internally, ammonium picrate was used for a time as an 
antimalarial and anthelmintic, but it soon proved unsuitable for 
either purpose. 

NAPHTHALENUM, U. S. P. 

(Napb.tb.alen; Naphthalin; Tar Camphor; C 10 H 8 . ) 

Naphthalen is a hydrocarbon obtained by distilling coal-tar 
between i8o°-25o° C. (356°-482° F.). It occurs in white, 
shining scales, having a strong odor of coal-tar and a burning 
taste. It is insoluble in water, soluble in 13 parts of alcohol, 
and in all proportions in ether and chloroform. The dose is 
from 2-10 gr. (o. 1 3-0.6 gm.). 

Therapeutics. — Naphthalen was at one time used as an 
intestinal antiseptic in diarrhea, but it has been almost com- 
pletely displaced by betanaphthol. 

BETANAPHTHOL, U. S. P. 

(Betanapbtol ; C 10 H,OH.) 

Betanaphthol is a phenol occurring in coal-tar, but usually 
prepared artificially from naphthalen. It occurs in white, 
shining scales or as a yellowish-white crystalline powder, having 
a faint, phenol-like odor and a pungent taste. It is soluble in 



ACIDUM SALIC YLICUM. 395 

about 950 parts of water, and freely soluble in alcohol, ether, 
and chloroform. The dose is from 2-10 gr. (0.13-0.6 gm.). 

Physiologic Action and Therapentics.— Betanaphthol 
resembles carbolic acid in its action, but it is less poisonous. 
Large doses, however, not infrequently give rise to considerable 
irritation of the genito-urinary tract. It is eliminated in the urine 
in combination with glycuronic acid. Locally, in concentrated 
form, it is irritating to mucous membranes and raw surfaces. 
Absorption readily follows its local application. Its germicidal 
power is much greater than that of carbolic acid. 

Internally, betanaphthol is useful as an antiseptic in chronic 
diseases of the stomach and in diarrhea. Bouchard and others 
have recommended it also in typhoid fever ; the course of the 
disease, however, is not affected in the least by it, although it 
is sometimes of service in lessening flatulence and diarrhea. 
In doses of 15 grains (1.0 gm.), repeated in two hours, it has 
been used successfully in uncinariasis or hook-worm disease. 
It is best administered in capsules. 

Externally, it is efficacious as a parasiticide and stimulant 
application in certain diseases of the skin. In scabies and in 
ringworm of the scalp or body it may be employed as an oint- 
ment in the strength of a dram (4.0 gm.) to the ounce (30.0 
gm.). Ointments containing from \- 1 dr. (2.0-4.0 gm.) to the 
ounce (30.0 gm.) have been used also with some benefit in 
psoriasis, but, as a rule, the drug is less useful in this disease 
than either chrysarobin or tar. 

Ben£onapnthol. — This compound is prepared by acting on 
betanaphthol with benzoyl chlorid. It is said to escape the 
action of the gastric juice, and to be split up into its compo- 
nents in the intestine. In doses of from 5-10 gr. (0.3-0.6 gm.) 
it is a good intestinal antiseptic, having at least one advantage 
over betanaphthol in being tasteless. 

Betanaphthol-bismnth {Orphol). — This preparation is a 
combination of bismuth oxid and betanaphthol. It is a light- 
brown, insoluble powder, odorless and tasteless. As its de- 
composition is mainly effected after it leaves the stomach, it is 
found efficacious in the various forms of intestinal catarrh. 
The dose is from 10-30 gr. (0.6-2.0 gm.). 

ACIDUM SALICYLICUM, U. S. P. 

(Salicylic Acid; HC 7 H 6 3 .) 

Salicylic acid is an organic acid contained in wintergreen, 
birch, and various other plants, but chiefly prepared artificially 
by acting on phenol with caustic soda and carbon dioxid. It 
occurs in fine white needles or as a crystalline powder, odor- 
less, and of a sweetish, acrid taste. It is soluble in 308 parts 



396 GERMICIDES, ANTISEPTICS, AND DEODORIZERS. 

of water, 2 parts of alcohol, 2 parts of ether, and 60 parts of 
glycerin. The dose is from 5-20 gr. (0.3-1.3 gm.). 

Physiologic Action. — Single, moderate doses of salicylic 
acid are not followed, as a rule, by any appreciable symptoms. 
Large doses, or even moderate doses in susceptible subjects, 
however, give rise to a feeling of fulness in the head and ring- 
ing in the ears, and, perhaps, to deafness, dimness of vision, 
flushing of the surface, and perspiration. Toxic doses, in addi- 
tion to the above symptoms, produce labored breathing, fol- 
lowed by shallow respiration, subnormal temperature, a slow, 
feeble pulse, olive-green urine, albuminuria, delirium, ocular 
palsies, unconsciousness, paralysis of the sphincters, and col- 
lapse. Death usually results from asphyxia. In some cases 
the delirium has been associated with delusions and hallucina- 
tions ; in others, there has been an erythematous, urticarial, 
or ecchymotic eruption. 

Circulatory System. — Moderate doses slightly raise the 
blood-pressure, probably by constricting the deep vessels 
through a central action. The superficial vessels are dilated. 
Large doses lower the blood-pressure by depressing the heart 
and vasomotor center. The administration of salicylic acid 
results in a moderate leukocytosis. In poisoning, the red cells 
suffer disintegration. 

Nervous System. — Salicylic acid has comparatively little 
influence on the nervous system. The fulness in the head and 
the disorders of hearing are probably the result of some dis- 
turbance of the circulation ; the amblyopia has been attributed 
to the same cause, but there is a suspicion that it is produced 
by changes in the ganglion-cells of the macula. 

Respiratory System. — Toxic doses appear first to stimulate 
and then to paralyze the respiratory center. 

Alimentary Canal. — Its presence in the alimentary canal, 
even in small quantities, tends to retard the action of the diges- 
tive ferments. It is a distinct irritant to the mucous membrane 
of the stomach, and, in consequence, nausea and vomiting are 
frequently induced by its administration. It appears to have 
some power to increase the secretion of bile. 
Sk- Metabolism. — There is considerable testimony to show that 
salicylic acid increases the output of urea, uric acid, and the 
sulphur compounds, but how this is brought about has not 
been determined. 4. 

Temperature. — In health salicylic compounds do not exert 
much influence on the bodily temperature ; in fever, however, 
they have a marked antipyretic effect, which probably results 
from dilatation of the cutaneous vessels and an increased loss 
of heat. 






9* 



ACIDUM SALICYLICUM. 397 



Absorption and Elimination. — Salicylic acid enters the 
blood as an alkaline salicylate. It is eliminated from the body 
in most of the secretions, but chiefly in the urine, in which it 
appears for the most part as salicyluric acid, a compound of 
salicylic acid and glycocoll, although some of the drug is ex- 
creted unchanged. The greenish discoloration of the urine is 
said to be due to the formation of indican or of pyrocatechin. 
Its excretion is attended by some increase in the flow of urine, 
owing, no doubt, to stimulation of the kidneys. Large doses 
may excite nephritis. 

Action on Micro-organisms. — Its germicidal properties are 
no less pronounced than those of carbolic acid. 

Therapeutics. — The chief use of salicylic acid and its al- 
lied compounds is in acute rheumatism, on which disease they 
exert a specific influence, mitigating the pain, lowering the tem- 
perature, lessening the liability to cardiac complications, and 
shortening the duration of the attack. The manner in which 
these drugs produce their favorable influence is not under- 
stood, but it is possible that they may act by neutralizing the 
toxins of the infective agent. From 10 to 15 gr. (0.6-1.0 gm.) 
of the acid or of one of its salts should be given every two or 
three hours until tinnitus develops or the articular symptoms 
are favorably affected, when the interval between the doses 
may be gradually increased. Salicylic compounds are also J 
efficacious in certain affections which seem to be in some way 
related to rheumatism, such as tonsillitis, chorea, lumbago, 
sciatica, erythema nodosum, and neuritis due to cold. In 
chronic rheumatism they are of little value, and in rheumatoid 
arthritis and gout they are useless. 

In diabetes mellitus, for which they were originally recom- 
mended by Ebstein, they are frequently of service in lessening 
the excretion of urine and in relieving pruritus. 

Salicylic acid is no longer in use as a topical antiseptic, but 
some of the less soluble combinations of it are employed with 
advantage in checking fermentation in the intestinal canal. 

Locally, the acid is an excellent remedy in certain diseases 
of the skin. The following dusting-powder often affords relief 
in hyperidrosis : 

R Acidi salicylici, gr. xxx (2.0 gm.) ; 

Acidi borici, gj (4.0 gm.); 

Amyli, gss (15.0 gm.). M. 

Ointments or pastes containing from 20-40 gr. (1.3-2.6 gm.) 
to the ounce (30.0 gm.) are of service in many cases of subacute 
and chronic eczema. Dissolved in collodion, a dram (4.0 gm.) 



398 GERMICIDES, ANTSSEPTICS, AND DEODORIZERS. 

to the ounce (30.0 c.c.), it is employed with success in remov- 
ing co?') is and warts. 

Contraindications. — Salicylic compounds must be with- 
held or used with great care when there is renal irritation or 
active disease of the middle ear. 

Administration. — Salicylic acid is more irritating to the 
stomach than its salts, and for this reason the latter are gener- 
ally selected for internal use. The acid obtained from oil of 
wintergreen has no advantage over the cheaper synthetic acid 
if the latter be of official quality. Salicylic compounds should 
be given after meals, in some aromatic water, well diluted. 
When in rheumatism they are not tolerated in any form by 
the stomach, the acid may be applied directly to the joints, as 
in the following formula : 

R Acidi salicylici, giss (6.0 gm.) ; 

Olei terebinthinae, f gj (4.0 c.c.) ; 

Adipis lanae hydrosi, ^ss (15.0 gm.) ; 

Adipis benzoinati, q. s. ad ^ij (60.0 gm.). M. 

Sig. Spread on muslin and keep in place by means of a flannel 
bandage. 

SODII SALICYLAS, U. S. P. 

(Sodium Salicylate; NaC 7 H 6 3 .) 

Sodium salicylate is a white amorphous powder, odorless, 
and of a sweetish, saline taste. It is soluble in 0.8 part of 
water and in 6 parts of alcohol. The dose is from 5-20 gr. 
(0.3-1.3 gm.). 

Therapentics. — It is the most commonly used of all the 
salts of salicylic acid. Its action is the same as that of the 
acid, but it has advantages in being more soluble in water and 
less irritant to the stomach. Like all salicylic compounds, 
however, it should be given after meals, well diluted. In 
rheumatism it may be combined advantageously with an alkali, 
as in the following formula : 

R Sodii salicylatis, 

Potassii bicarbonatis, aa ^ss (15.0 gm.) ; 

Aquse menthae piperitae, q. s. ad f^iv (115.0 ex.). M. 

Sig. A dessertspoonful in water four times a day. 

LITHII SALICYLAS, U. S. P. 

(Lithium Salicylate; LiC,H 5 O s .) 

Lithium salicylate is a white, deliquescent powder of a 
sweetish taste. It is freely soluble in water and in alcohol. It 
is somewhat less irritating to the stomach than sodium salicy- 
late, for which it may be substituted. The dose is from 5-20 
gr. (0.3-1.3 gm.). 



ACIDUM SALICYLICUM. 399 

AMMONII SALICYLAS, U. S. P. 

(Ammonium Salicylate; NH 4 C 7 H 5 8 .) 

Ammonium salicylate occurs in clear, colorless prisms, freely- 
soluble in water. Wood recommends it as being more agree- 
able to the taste and less depressing and less nauseating than 
the sodium salt. The dose is from 5-20 gr. (0.3-1.3 gm.). 

STRONTII SALICYLAS, U. S. P. 

(Strontium Salicylate ; Sr(C 7 H 6 3 ) 2 .) 

Strontium salicylate occurs in colorless octahedral crystals, 
freely soluble in water. It is much less irritating to the stom- 
ach than the sodium salt. The dose is from 5-20 gr. (0.3-1.3 
gm.). 

METHYLIS SALICYLAS, U. S. P. 

(Methyl Salicylate; Artificial Oil of Wintergreen ; CH 3 C 7 H 6 3 .) 

Methyl salicylate is prepared synthetically by distilling 
methyl alcohol with salicylic and sulphuric acids. It is a 
colorless or slightly yellowish oily liquid, having the charac- 
teristic odor and taste of wintergreen. It appears to be almost 
identical in its properties and actions with the natural oil of 
wintergreen (Oleum Gaultherice, U. S. P.) and the oil of sweet 
birch {Oleum Betulce, U. S. P.), which are composed almost en- 
tirely of pure methyl salicylate. The dose of either the artificial 
product or of the natural oils is from 5-20 min. (0.3-1.2 c.c). 

Therapeutics. — These preparations may be used internally 
in rheumatism interchangeably with salicylic acid and the min- 
eral salicylates. They are more likely, however, to disturb 
digestion than either ammonium or strontium salicylate, and, 
moreover, their strong flavor often turns the patients against 
them. Externally, they serve an excellent purpose as local 
applications to the affected joints. For internal use they may 
be given on sugar, in capsules, or in an emulsion. As a local 
remedy methyl salicylate is as efficient as oil of wintergreen, 
and very much cheaper. 

Mesotan. — This is the trade name of the methyl oxymethyl 
of salicylic acid. It is a yellow liquid, miscible with oils and 
other organ solvents. Diluted with from 20 to 30 per cent, 
of some bland oil, it has been recommended as a local remedy 
in rheumatic affections. Though more irritating, it does not 
appear to be any more effective than methyl salicylate or oil of 
gaultheria. Moreover, it is costly. 

BISMUTHI SUBSALICYLAS, U. S. P. 

(Bismuth Subsalicylate; Bi(C 7 H 5 3 ) 3 Bi 2 s .) 

Bismuth subsalicylate is a white, odorless, tasteless, and in- 



400 GERMICIDES, ANTISEPTICS, AND DEODORIZERS. 

soluble powder, containing about 62 per cent, of bismuth tri- 
oxid. It is used almost entirely as an intestinal antiseptic and 
astringent in diarrhea. The dose is from 5-20 gr. (0.3-1.3 
gm.). 

PHENYLIS SALICYLAS, U. S. P. 

(Phenyl Salicylate ; Salol ; C 6 H 6 C T H 6 3 .) 

Salol is a white crystalline powder, of a faintly aromatic 
odor, and almost tasteless. It is nearly insoluble in water, but 
soluble in 5 parts of alcohol, 0.3 part of ether, and readily in 
oils. The dose is from 5-20 gr. (0.3-1.3 gm.). 

Physiologic Action and Therapeutics.— Salol resists 
to a great extent the action of the gastric juice, but is slowly 
broken up by the alkaline fluids of the intestine into salicylic 
acid (60 parts) and carbolic acid (40 parts). After very large 
doses poisoning results from carbolic rather than from salicylic 
acid. 

Like other salicylic compounds, it is useful in the various 
manifestations of rheumatism, but in the more severe forms of 
the disease its action is less prompt and powerful than that of 
sodium or ammonium salicylate. As its dissociation does not 
occur until it has escaped from the stomach, it may be em- 
ployed advantageously as an antiseptic in all forms of intestinal 
catarrh associated with abnormal fermentation. In cystitis and 
urethritis it is often combined with such drugs as oil of sandal- 
wood and balsam of copaiba for the purpose of sterilizing the 
urine. 

It should always be used with considerable caution when 
there is evidence of active nephritis. 

It may be prescribed in powders, capsules, pills, or in an 
emulsion. Tablets and hard pills may fail of solution and 
escape in the feces. 

Aspirin or Acetylsalicylic Acid. — This compound dif- 
fers from salol in possessing an acetyl instead of a phenol 
radical. It is a white crystalline powder having an acidulous 
taste, soluble in 100 parts of water and in 5 parts of alcohol. 
It passes unchanged through the stomach, but undergoes dis- 
sociation in the alkaline fluids of the duodenum, liberating 
salicylic acid. It acts like the latter, but being split up slowly 
it is less irritant and less prone to cause unpleasant side effects ; 
at the same time its action is less prompt and less powerful 
than that of the free acid. It is incompatible with alkalies and 
their carbonates and bicarbonates. It cakes with antipyrin. 
Heat and moisture also decompose it. The dose is from 5-1$ 
gr. (0.3-1.0 gm.) in capsules, cachets, or powders. 



ACIDUM BENZOICUM. 401 

Salophen {Acetyl-paramido-phenyl Salicylate). — This is a 
compound ether of salicylic acid, occurring in tasteless and in- 
odorous white scales, insoluble in water, but soluble in alcohol 
and ether. It contains about 50 per cent, of salicylic acid. It 
was introduced as a substitute for salol, on account of the ill 
effects thought to result from the liberation of phenol from the 
latter. It is decomposed in the intestine into salicylic acid and 
the comparatively innocuous acetyl-paramido-phenyl. It is 
much less active in rheumatism than sodium salicylate, but 
being tasteless and unirritating to the stomach, it is a valuable 
remedy in the milder manifestations of the disease. The dose 
of salophen is from 5-30 gr. (0.3-2.0 gm.). 

Betol differs from salol in containing a naphtyl instead of a 
phenyl group. It is decomposed in the intestine into beta- 
naphthol and salicylic acid. It is used in the same doses and 
for the same purposes as salol. 

SALICINUM, U. S. P. 

(Salicin; C 13 H 18 O r ) 

Salicin is a glucoside obtained from several species of 
willow (salix) and poplar (poptdus). It occurs in white, silky 
needles, odorless, and of a very bitter taste. It is soluble in 
21 parts of water and in 71 of alcohol. The dose is from 
10-40 gr. (0.6-2.6 gm.). Salicin was the first of the salicylic 
preparations to be used in rheumatism, Maclagen, of Dundee, 
having prescribed it in 1874, a year before the introduction of 
salicylic acid by Buss, of Basle. It is partially converted in 
the body into salicylic acid, and rapidly appears in the urine 
partly as salicin and partly as saligenin, salicyluric acid, and 
salicylic acid. It is well borne by the stomach, but it is far less 
active and reliable than salicylic acid or the salicylates. 

ACIDUM BENZOICUM, U. S. P. 

(Benzoic Acid; HC 7 H 5 2 .) 

Benzoic acid (see p. 277) is an organic acid contained largely 
in benzoin, balsam of Peru, and balsam of tolu. It is obtained 
from benzoin, from the urine of herbivorous animals, and arti- 
ficially from toluene, a coal-tar derivative. It occurs in white 
or slightly yellow scales or needles, of an aromatic odor and 
taste. It is sparingly soluble in water, but freely so in alcohol, 
ether, and chloroform. The dose is from 5-20 gr. (0.3—1.3 
gm.). 

Therapeutics. — The germicidal power of benzoic acid is 
about equal to that of salicylic acid. Internally, it is very use- 

26 



402 GERMICIDES, ANTISEPTICS, AND DEODORIZERS. 

ful as a urinary antiseptic in cystitis with ammoniacal urine. 
The acid itself and its salts have also been employed to some 
extent as intestinal antiseptics in catarrhal enteritis. Senator 
and others have recommended the benzoates in rheumatism, 
but they have been found much less efficacious than the salicy- 
lates. 

Externally, in the form of balsam of Peru (see p. 279), ben- 
zoic acid is much used as a parasiticide in scabies. 

FORMALDEHYDUM. 

(Formaldehyd ; Formic aldehyd ; Oxymethylene ; CH 2 0.) 

Formaldehyd is a colorless gas obtained by oxidizing 
methyl alcohol (wood-alcohol). A 37 per cent, aqueous solu- 
tion of the gas is official as Liquor Formaldehydi. The latter 
is a clear, colorless, neutral liquid, of a very pungent odor and 
a caustic taste. Other preparations of the same nature are 
variously known as formalin, formal, methylaldehyd, etc. In 
solution the gas readily polymerizes, forming paraformaldehyd 
or paraform (trioxymethylene, (CH 2 O s )), a white crystalline 
powder, which yields formaldehyd on heating. 

Physiologic Action and Therapeutics. — Formaldehyd 
is an intensely irritating gas, causing, when inhaled, severe con- 
gestion and even inflammation of the mucous membrane of the 
entire respiratory tract. On cutaneous surfaces concentrated 
solutions or even dilute solutions if the contact be prolonged, 
not infrequently excite an erythematous or eczematous erup- 
tion. Concentrated solutions coagulate albuminous matters, 
but weak solutions do not. To higher animals it is compara- 
tively harmless, but prolonged inhalation may cause fatal 
pneumonitis. In a case cited by Zorn, an ounce (30.0 c.c.) of 
formalin produced the following symptoms : burning in the 
throat and stomach, nausea, vomiting, diarrhea, a weak, feeble 
pulse, dyspnea, cyanosis, vertigo, and anuria lasting for several 
hours. The urine passed later contained albumin and casts. 
Large doses, as in Kliiber's case, may cause also stupor and 
coma. The antidote for formaldehyd poisoning is ammonia in 
the form of the water or spirit, which combines with formal- 
dehyd to form the harmless hexamethylenamin (urotropin). 
The fate of formaldehyd in the body is not definitely known, 
but a portion at least appears to be eliminated in the urine 
unchanged. 

Germicidal Power. — The germicidal power of formaldehyd 
is little, if at all, inferior to that of mercuric chlorid. A I per 
cent, solution of the official preparation kills pure cultures of 



FORMALDEHYD. 403 

pathogenic bacteria in an hour, and, according to Harrington, 
bacteria of the highest resistance, when freely exposed to an 
atmosphere produced by vaporizing 1 10 c.c. of liquor formal- 
dehydi in each 1000 cubic feet, are killed within two and a 
half hours. Though very diffusible, formaldehyd has little 
penetrating power ; it cannot be considered, therefore, except 
under the most favorable conditions, more than a surface dis- 
infectant. As it unites readily with hydrogen sulphid, mer- 
captan, ammonia, and fetid ammonia bases to form inodorous 
compounds, it is a powerful deodorizer. 

As a surface disinfectant for rooms it has decided advantages 
in being comparatively harmless to the higher forms of animal 
life, and in having no injurious effects on delicate fabrics or 
metals. On account of its weak penetrating power, however, 
it is not a suitable disinfectant for upholstered furniture, carpets, 
bedding, books, etc. As the aqueous solution when vaporized 
from an open vessel loses most of its germicidal power through 
the polymerization of the formaldehyd into paraform, some 
special device has been found necessary for securing an ade- 
quate supply of the gas. Lamps devised for generating for- 
maldehyd directly from methyl alcohol were first employed, 
but they did not prove reliable. A sufficient quantity of gas 
may be obtained by vaporizing paraform tablets in a suitable 
lamp, or by subjecting a fine stream of the aqueous solution 
by means of a special contrivance to a high degree of heat. 
If the paraform lamp be used, it must be placed inside the 
room to be disinfected; but if the second form of apparatus be 
employed, it may be placed outside, the gas being conducted 
mto the room by means of a tube passed through the keyhole. 
At least 60 paraform tablets or a quart (1.0 L.) of the official 
solution should be vaporized for every 1000 cubic feet of room 
to be disinfected. Another simple but very reliable method is 
to add formalin to powdered potassium permanganate. The 
mixture should be made in a galvanized iron pail that has been 
slightly heated beforehand, and 20 ounces (570.0 c.c.) of for- 
malin and 8 J ounces (245.0 c.c.) of the permaganate should be 
used for every 1000 cubic feet of room space requiring disin- 
fection. To secure the best results with any of these methods 
the room should be sealed as hermetically as possible before 
the operation, and should be kept closed after it for at least ten 
hours. Subsequently ammonia water may be evaporated in 
the room to destroy the formaldehyd. 

An excellent method of sterilizing small i?istruments without 
dulling or tarnishing them is to expose them for ten minutes 



404 GERMICIDES, ANTISEPTICS, AND DEODORIZERS. 

in an air-tight tin box to the vapor evolved from a 5 gr. (0.3 
gm.) paraform tablet. 

A 5 per cent, solution of the official preparation (1 : 20 parts 
of water) in excess is a reliable disinfectant for stools and sputa. 

The irritant properties of formaldehyd detract from its use- 
fulness in general surgical work, but a I or 2 per cent, solution 
of liquor formaldehydi may be employed to cleanse wounds 
and to irrigate sinuses and suppurating cavities. A solution of 
the same strength containing glycerin makes a useful wash for 
the nose and throat in infectious diseases. Solutions of from 
I : 1000 to 1 : 500 have been found serviceable in chronic otor- 
rhea. A solution of 1 : 2000 has been used successfully as a 
collyrium, especially in ulcerative keratitis. A lotion contain- 
ing from 2 to 4 per cent, of liquor formaldehydi is sometimes 
very efficacious in bromidrosis and hyperidrosis. 

There is considerable evidence to show that formaldehyd 
added to milk as a preservative lessens its nutritive value and 
interferes with digestion ; it is but fair to state, however, that 
Tunnicliffe and Rosenheim conclude from a recent study of 
the subject that in the proportion ordinarily used the drug has 
no appreciable influence on perfectly healthy children. 

Incompatibles. — Ammonia, alkalis, gelatin, tannin, and 
mineral salts. 

Glutol. — This is a combination of formaldehyd and gelatin, 
appearing as a gray, odorless, and tasteless powder. It has 
been well spoken of as a substitute for iodoform in the treat- 
ment of infected wounds and ulcers. 

Tannoform (see p. 357) is a combination of formaldehyd 
and tannic acid. It is chiefly useful as a dusting-powder in 
hyperidrosis. 



HEXAMETHYLENAMINA, U. S. P. 

(Hexamethylenamin ; Urotropin; (CH 2 ) 6 N 4 .) 

Hexamethylenamin, or urotropin, is the product of the action 
of formaldehyd on ammonia. It occurs in colorless rhombic 
crystals, odorless, and of a sweetish taste. It is soluble in 1.3 
parts of water, less soluble in alcohol, and insoluble in ether. 
It is readily decomposed by acids and by heat. The dose is 
from 3-10 gr. (0.2-0.6 gm.), dissolved in water, thrice daily 
between meals. 

Physiologic Action and Therapeutics. — When taken 
internally in moderate doses, urotropin produces no special 
symptoms, but is rapidly absorbed and rapidly eliminated, 
partly unchanged and partly as formaldehyd. The bulk of it 



HEXAME THYLENAMINA. 40 5 

escapes in the urine, but, according to Crowe, after large doses 
enough appears in the bile and cerebrospinal fluid to exercise 
a decided bactericidal action. Urine passed shortly after the 
administration of urotropin remains sterile for a long period, 
even when exposed to the air. It does not materially increase 
the quantity of urine nor affect the elimination of solids, but it 
has more power than any other internal remedy of ridding 
that secretion of bacteria. Large doses, especially if long con- 
tinued, sometimes cause frequent micturition, burning in the 
bladder, and even hematuria ; but these symptoms speedily 
disappear upon the withdrawal of the drug. As a urinary anti- 
septic urotropin is most efficacious in typhoid cystitis, in chronic 
cystitis accompanying prostatic enlargement ox urethral stricture \ 
and in simple bacteriuria. Its power to arrest ammoniacal de- 
composition of the urine is sometimes truly remarkable. To 
secure a lasting effect, however, it should be given for a con- 
siderable period after the urine has become apparently sterile. 
If the urine be alkaline when secreted by the kidneys, 
formaldehyd may not be liberated; in such cases urotropin, 
to be effectual, should be preceded by a course of benzoic 
acid. 

When bacteria, instead of being free in the urine, are chiefly 
in the tissues of the bladder, as they are in tuberculous and 
gonorrheal cystitis, urotropin is of little value. 

As the urine of typhoid patients frequently contains typhoid 
bacilli long after the establishment of convalescence, and as 
this secretion is frequently the means, no doubt, of spreading 
the infection, Horton-Smith, Richardson, Gwyn, and others 
have advocated as a routine prophylactic measure the ad- 
ministration of urotropin during the last weeks of the 
disease. 

Keyes, Otis, and others have found the drug of value as a 
prophylactic remedy in preventing infection when administered 
for several days before and several days after operations on the 
genito-uri7iary tract. It is important, however, that it should 
not be used too freely, since when eliminated in large quantities 
it tends to retard healing. 

Crowe believes that urotropin maybe of great value both in 
preventing and in combating i?ifection of the gall-bladder and 
of the cerebrospinal meninges. 



406 GERMICIDES, ANTISEPTICS, AND DEODORIZERS. 
CHLORUM. 

(Chlorin; CI.) 

Chlorin is a heavy, yellowish-green gas, of a suffocating 
odor and a caustic taste. It may be prepared by heating to- 
gether sodium chlorid, sulphuric acid, and manganese dioxid 
or by acting upon chlorinated lime with an acid. 

Preparation. Dose. 

Liquor Chlori Compositus, U. S. P. (contains at 
least 0.4 per cent, of the gas with some 
oxides of chlorin and potassium chlorid) . . 1-2 fl. dr. (4.0-8.0 c.c). 

Physiologic Action and Therapeutics. — In concen- 
trated form chlorin acts as a powerful irritant, even upon cuta- 
neous surfaces. When inhaled it excites pain in the chest, 
cough, dyspnea, spasm of the vocal cords, and, ultimately, 
mucopurulent or fibrinous bronchitis with inflammation and 
edema of the lungs. Owing to its affinity for hydrogen and 
its power to separate nascent oxygen from water, it is an ener- 
getic germicide, especially in the presence of moisture. For 
the same reasons it is also an active deodorizer. 

As a gaseous disinfectant for rooms, however, it has serious 
disadvantages in being exceedingly irritant and poisonous, in 
being destructive to wall-paper and other colored fabrics, and 
in being so heavy that it diffuses with difficulty. The com- 
pound solution of chlorin (chlorin water) is a very unstable 
preparation ; for disinfecting excreta it is, therefore, less reli- 
able than chlorinated lime. Largely diluted, it has been used 
to some extent as a wash for fetid sores and as a spray for the 
nose and throat in infectious diseases. Internally, it has been 
recommended as an intestinal antiseptic in typhoid fever, but it 
is of very doubtful utility. 

CALX CHLORINATA, U. S. P. 

(Chlorinated Lime.) 

Chlorinated lime is a preparation containing not less than 30 
per cent, of available chlorin, and is obtained by acting on 
slaked lime with chlorin gas. It consists chiefly of the hypo- 
chlorite and the chlorid of calcium, and appears as a grayish- 
white powder, having a strong odor of chlorin and a disagree- 
able saline taste. It is partially soluble in water and in 
alcohol. 

Action and Uses. — A solution of 0.5-1 per cent, of freshly 
prepared chlorinated lime kills most bacteria within ten min- 
utes. A 0.5 per cent, solution makes a reliable disinfectant 



ACIDUM SULPHUROSUM. 407 

wash for bare walls and woodwork. A solution of the same 
strength is also useful for disinfecting white clothes. A 1 per 
cent, solution may be employed to sterilize feces and sputa. 

Wquor Sodae Chlorinatse, U. S. P. (Solution of Chlo- 
rinated Soda, or Labarraque's Solution). — This is a solution of 
several chlorin compounds of sodium containing at least 2.4 
per cent, of available chlorin. It is used for the same pur- 
poses as chlorinated lime. 

ACIDUM SULPHUROSUM, U. S. P. 

(Sulphurous Acid; H 2 S0 3 .) 

Sulphurous acid gas, or sulphur dioxid (S0 2 ), when required 
in large amounts, is usually obtained by burning sulphur. In 
the official preparation, however, which is a 6 per cent, aque- 
ous solution of sulphur dioxid, the gas is obtained by reducing 
sulphuric acid with charcoal. 

Physiologic Action and Therapeutics. — Sulphur di- 
oxid is an intensely irritating, suffocating gas, quite capable, 
if inhaled in sufficient quantity, of destroying life. It has con- 
siderable germicidal power, especially in the presence of mois- 
ture, and before the introduction of formaldehyd it was the 
most popular gaseous disinfectant for rooms, hospital wards, 
and ships. Formaldehyd, however, being much more reliable 
and being without injurious effects on colored fabrics, has 
largely displaced it. To be at all effective, at least 4 pounds 
of sulphur should be burned for every 1000 cubic feet of air- 
space in the apartment. The sulphur, in the form of small 
fragments, should be put in a pan, and the latter should be 
placed inside of a tub partly filled with water. Before being 
ignited the fragments should be well saturated with alcohol. 
To secure the required amount of moisture steam may be gen- 
erated at the same time or the walls and contents of the room 
may be previously sprayed with water. Key-holes and other 
openings should be carefully sealed, and the gas should be 
allowed to act for from ten to twelve hours. 

A more convenient method of sulphurous acid disinfection, 
but one not always available, is to use the gas that has been 
liquefied under pressure and has been stored in metal cylinders. 

Official sulphurous acid, though somewhat irritant, is a 
reliable parasiticide in ringworm of the body. It may be applied 
in full strength or diluted. As light and air gradually con- 
vert sulphurous into sulphuric acid, only fresh preparations 
should be employed. 



408 GERMICIDES, ANTISEPTICS, AND DEODORIZERS. 
AQUA HYDROGENII DIOXIDI, U. S. P. 

(Solution of Hydrogen Dioxid; Solution of Hydrogen Peroxid.) 

Hydrogen dioxid (H 2 2 ) is a very unstable compound, pre- 
pared by the action of mineral acids or barium dioxid. It is 
employed in medicine only in the form of aqueous solutions. 
The official solution, when freshly prepared, contains about 3 
per cent, by weight, of the pure dioxid, an amount correspond- 
ing to about 10 volumes of available oxygen. This solution 
is a colorless liquid, odorless, of a slightly acidulous taste, and 
producing a foam in the mouth. It contains a small amount 
of free acid as a preservative. Sunlight, protracted agitation, 
heat, and many metallic substances serve to decompose it into 
oxygen and water. 

Physiologic Action and Therapeutics. — The therapeu- 
tic value of hydrogen dioxid depends upon the readiness with 
which it parts with oxygen when it is brought in contact with 
the tissues and fluids of the body. When it is applied to a 
suppurating wound, effervescence follows from the liberation 
of oxygen, the pus is discharged, and the surface is left per- 
fectly clean and protected by a delicate coagulum. When 
taken internally it causes no special symptoms, its decomposi- 
tion into oxygen and water being speedily effected in the 
stomach. According to Egbert, it has no inhibitive influence 
on the unorganized ferments, such as ptyalin and pepsin. 
When injected intravenously or subcutaneously, however, it 
may kill suddenly by forming gaseous emboli in the blood. 
The same accident has also resulted from its introduction into 
one of the large serous sacs. Owing to its oxidizing power 
also it is an active germicide and deodorizer. A 20 per cent, 
solution of the official preparation quickly destroys pyogenic 
cocci and other non-spore-bearing bacteria. As an antiseptic 
for general surgical purposes its drawbacks are its proneness 
to deteriorate and the short duration of its action ; its advan- 
tages are its freedom from odor and from irritant and toxic 
properties. Its chief use is in the preliminary treatment of 
septic wounds, abscess cavities, and fistulous tracts ; its efficacy 
in these cases being due in part to its antiseptic action and in 
part to its mechanical action in expelling pus, blood-clots, and 
detritus. It is generally applied diluted with from 1 to 3 parts 
of water. It should not be injected into deep abscesses, unless 
there is a free exit for the gas and pus, as otherwise serious 
harm may result from the increased tension within the cavity ; 
neither should it be introduced, under any circumstances, into a 
large serous sac, like the pleura or peritoneum. 



POTASSII PERMANGANAS. 409 

A 25-50 per cent, solution of the official preparation makes 
an excellent wash or spray for the nose and throat in diph- 
theria. If an atomizer be used, the tube and nozzle should be 
of hard rubber or of glass, as contact with metal favors the 
decomposition of the dioxid. A solution of the same strength 
is also serviceable in mercurial stomatitis, in noma, and in fol- 
licular tonsillitis. Harris has found copious rectal injections 
of a dilute solution (1 '.4 or 8) of some benefit in amebic dysen- 
tery. 

The bleaching properties of hydrogen dioxid render it use- 
ful, according to Bulkley, in hiding superflous black hair upon 
the face of women. Its physical action also makes it useful 
in removing the particles of carbon in gunpowder burns. 

With the hope that it might impart some of its oxygen to 
the blood it has been recommended internally in a number of 
diseases, but in none has it gained any reputation. 

POTASSII PERMANGANAS, U. S. P. 

(Potassium Permanganate; KMn0 4 .) 

Potassium permanganate occurs in the form of slender, dark- 
purple prisms, odorless, and of a sweetish, astringent taste. It is 
soluble in 15 parts of water, and is decomposed by alcohol. 
The dose is from 1-3 gr. (0.06-0.2 gm.) in pill form, after 
meals. 

Physiologic Action and Therapeutics. — In concen- 
trated solution potassium permanganate acts as an irritant or 
mild caustic. By the mouth, if the dose be sufficiently large, 
it produces the symptoms of a corrosive poison. In the pres- 
ence of organic matter it quickly yields its oxygen ; hence it 
is a prompt germicide and deodorant. Unfortunately, its use- 
fulness is considerably restricted by the facility with which it is 
rendered inert by deoxidation. Solutions of potassium per- 
manganate, however, make valuable deodorizing and detergent 
washes in many diseases attended with offensive discharges ; 
thus, solutions of from 1-3 gr. (0.06-0.2 gm.) to the ounce 
(30.0 c.c.) may be used with advantage in gangrenous stomatitis, 
cancer of the tongue, ozena, cancer of the uterus, foul idcers, and 
bromidrosis. A warm saturated solution makes a good disin- 
fectant for the hands, provided it be followed by a saturated 
solution of oxalic acid to reinforce the permanganate and to 
remove the stain. A solution of from 1 : 6000 gradually in- 
creased to 1 : 1000, used by irrigation or by injection, is quite 
efficacious in gonorrhea. 

Internally, potassium permanganate is used as an emmena- 
gogue (see p. 248) and as an antidote to morphin poisoning (see 

P.95). 



41 GERMICIDES, ANTISEPTICS, AND DEODORIZERS. 

Incompatibles. — Potassium permanganate has an exceed- 
ingly wide range of incompatibilities. With oxidizable sub- 
stances, especially organic ones, like alcohol and glycerin, it is 
explosive. 

CALX, U. S. P. 

(Lime; Quicklime; Burned Lime; CaO.) 

Lime is obtained by burning the purest natural varieties of 
calcium carbonate. It occurs in hard, white lumps, odorless, 
and of a sharp, caustic taste. It is soluble in 760 parts of 
water and is insoluble in alcohol. In the presence of water 
it evolves heat, and is gradually converted into calcium hydrate 
or slaked lime. Mixed with 3 or 4 parts of water, it forms a 
magma which is known as milk of lime. 

Preparations. Dose. 

Liquor Calcis, U. S. P \-2 fl. oz. (15.0-60.0 ex.). 

Syrupus Calcis, U. S. P. (lime, 6.5 parts ; 

sugar, 35; water, to make loo parts) . . £-1 fl. dr. (2.0-4.0 c.c.). 
Linimentum Calcis, U. S. P. (Carron oil : 

equal parts of lime water and linseed oil) . 
Potassa cum Cake (Vienna paste; 50 per 

cent, of each). 

Physiologic Action and Therapeutics. — Locally, lime 
is a quickly acting but superficial escharotic. It is never em- 
ployed by itself as a caustic, but in the form of potassa cum 
cake it is occasionally used to destroy small epitheliomata. 
When thoroughly mixed with putrefying matter quicklime 
favors disintegration, dispels offensive odors, and acts directly 
to a limited extent as a disinfectant. Freshly prepared milk of 
lime is sometimes employed to disinfect fecal discharges. Cal- 
cium hydrate, in the form of lime-water (see p. 172) and the 
syrup of lime, is used as an antacid and a mild astringent. 

SODII THIOSULPHAS, U. S. P. 

(Sodium Thiosulphate ; Sodium Hyposulphite; NajS 2 3 .5H 2 0.) 

Sodium thiosulphate, or sodium hyposulphite, occurs in white, 
transparent prisms, odorless, and of a cooling, somewhat bitter 
taste. It is freely soluble in water. The dose is from 5-20 gr. 
(0.3-1.3 gm.). m 

Therapeutics. — It is an excellent unirritating parasiticide in 
ringworm — tinea circinata and tinea sycosis — and in tinea versi- 
color. It may be applied either as a lotion or as an ointment in 
the strength of a dram (4.0 gm.) to the ounce (30.0 c.c. or gm.). 
It is also very effective in ivy -poisoning, in which it may be 
prescribed as follows : 



A CID UM B ORICUM. 4 1 1 

R Sodii thiosulphatis, ^j (30.0 gm.) ; 

Glycerini, fjjss (15.0 c.c. ) ; 

Aquae, q. s. ad fjfviij (240.0 c.c). M. 

Sig. Keep constantly applied. 

A solution of 30 gr. (2.0 gm.) to the ounce (30.0 c.c.) makes a 
useful mouth-wash in thrush. Internally, it has been found of 
service as an antiseptic in gastrectasis, when sarcinae and yeast 
are present in large quantities in the stomach-contents. 

Sodii Sttlphis, U. S. P. (Sodium Sulphite ; Na 2 S0 3 . 7H 2 0) 
and Sodii Bisulphis, U. S. P. (Sodium Bisulphite ; NaHSO s ). 
— These are salts sometimes employed as substitutes for 
sodium hyposulphite. 



ACIDUM BORICUM, U. S. P. 

(Boric Acid; Boracic Acid; H 3 BO s .) 

Boric acid occurs in colorless, transparent, pearly scales or 
crystals, odorless, and of a bitterish taste. It is soluble in 
18 parts of water, 15.3 of alcohol, and 4.6 of glycerin. The 
dose is from 5-20 gr. (0.3-1.3 gm.). 

Preparations. 
Liquor Antisepticus, U. S. P. (contains 2 per cent, of boric acid, 0.1 per 

cent, of benzoic acid, 0.1 per cent, of thymol, 25 per cent, of alcohol, and 

minute quantities of eucalyptol, oil of peppermint, oil of gaultheria, and 

oil of thyme). 
Glyceritum Boroglycerini, U. S. P. (contains 31 per cent, of boric acid in 

glycerin). 
Unguentum Acidi Borici, U. S. P. (10 per cent.). 

Physiologic Action. — In single moderate doses boric acid 
produces no appreciable symptoms. It is rapidly absorbed and 
rapidly eliminated, the bulk of it escaping in the urine within 
twenty-four hours after its administration. In very large doses 
it acts as an irritant poison. Its continued use in doses of a 
dram (4.0 gm.) a day not infrequently leads to a train of symp- 
toms to which the term borism has been applied. The most 
important features of this condition are digestive disturbances, 
marked dryness of the skin and mucous membranes, a ten- 
dency to alopecia, erythematous or eczematous eruptions, areas 
of local edema, albuminuria, and cachexia. The same phe- 
nomena have also been observed after repeated external appli- 
cations and rectal injections of boric acid. Although Annett 
found that kittens could not live longer than four weeks if fed 
upon milk containing small quantities of boric acid, it is the 
opinion of most experimenters (Rideal and Foulerton, Chitten- 



412 GERMICIDES, ANTISEPTICS, AND DEODORIZERS. 

den and Gies, Tunnicliffe and Rosenheim, Vaughan and Veen- 
boer) that the" drug when used as a food preservative does not, 
at least in adults, unfavorably affect nutrition. 

According to Sternberg, boric acid has pronounced antiseptic 
properties, but is inefficient as a germicide. 

Therapeutics. — As an unirritating, antiseptic wash, a solu- 
tion of boric acid (10 gr. : I fl. oz. — 0.6 gm. : 30.0 c.c.) has a 
wide range of usefulness in inflammatory diseases of the nose 
and throat. A solution of from 5-15 gr. (0.3-1.0 gm.) to the 
ounce (30.0 c.c.) may be employed with advantage as an eye- 
wash in simple conjunctivitis and during operations on the eye. 
Insufflations of boric acid are very valuable in chronic otorrhea ; 
in acute inflammation of the middle ear, however, especially 
when the discharge is profuse and contains much mucus, the 
drug may prove dangerous by clogging the outflow. Daily 
injections into the bladder of a warm solution (5 : 10 gr. to 1 
fl. oz. — 0.3—0.6 gm. to 30.0 c.c.) are often useful in cystitis. 
Lotions, ointments, and dusting-powders containing boric acid 
are extensively used in many acute inflammatory skin diseases, 
such as erythema intertrigo, eczema, superficial burns, and mili- 
aria. In pruritus a lotion of boric and carbolic acids frequently 
affords relief. 

R 



Phenolis, 


ITLxx (1.2 c.c); 


Acidi borici, 


gr. xl (2.6 gm.) ; 


Glycerini, 


f ^iss (6.0 c.c.) ; 


Aquae, 


q. s. ad f^iv (120.0 c.c). M. 



Dusting-powders containing boric acid are sometimes of 
service in bromidrosis : 

R Acidi borici, ^iss (6.0 gm.) ; 

Acidi salicylici, gr. xx (1.3 gm.) ; 

Pulv. amyli, 3iv (16.0 gm.). M. 

Internally, boric acid is of some value in cystitis with alka- 
line uri?ie, but, as a rule, it is less efficacious than urotropin or 
benzoic acid. 

Incompatibles. — Carbonates and bicarbonates. 

Sodii Boras, TJ. S. P. (Sodium Borate ; Borax ; Na 2 B 4 7 . 
ioH 2 0). — This salt occurs in colorless, transparent prisms or 
as a white powder, inodorous, and of a sweetish, alkaline 
taste. It is soluble in 20.4 parts of water and in 1 part of gly- 
cerin, and is insoluble in alcohol. The dose is from 5-20 gr. 
(0.3-1.3 gm.). Its action is very similar to that of boric acid, 
for which it is often substituted. Internally, it has been used 
with some success in epilepsy, but it is much less useful than 



GERMICIDES, ANTISEPTICS, AND DEODORIZERS. 413 

the bromids, and, moreover, in the large doses required it is 
often productive of grave constitutional symptoms. It is in- 
compatible with acids, metallic salts, and alkaloids. Glycerin 
slowly converts it into boric acid. 

CARBO. 

(Carbon.) 

Carbon is official in the following forms : 

Animal charcoal {Car bo Animalis, U. S. P.), purified animal 
charcoal {Carbo Animalis Purificatus, U. S. P.), and charcoal 
{Carbo Ligni, U. S. P.). Animal charcoal, or bone-black, is 
prepared by burning bones in closed iron cylinders. It is 
composed of carbon and calcium carbonate and phosphate. 
Purified animal charcoal is bone-black from which the earthy 
salts have been removed by hydrochloric acid. Wood char- 
coal is prepared from soft wood and is finely powdered. The 
dose is from \-2 dr. (2.0-4.0 gm.). 

Charcoal has the property of absorbing many times its own 
volume of gases or vapors. Owing to the oxygen condensed 
within its pores it has considerable oxidizing power, which may 
be utilized to destroy offensive gases, like hydrogen sulphid, 
and to hasten the decomposition of organic matter. Thorough 
wetting destroys its activity. As it is not absorbed when taken 
internally, it exerts no specific action on the body. 

Charcoal is employed chiefly as an absorbent and a deodor- 
ant. In the form of a poultice it was at one time a favorite 
application tor foul ulcers, but it has been largely displaced by 
more cleanly dressings. While it is a satisfactory agent for 
deodorizing fecal discharges, it has less disintegrating action 
than dry earth. 

Internally, it is sometimes useful as an absorbent in flatulent 
dyspepsia. In may be given as a powder or in lozenges. 

Animal charcoal is not used for medicinal purposes, but it is 
largely employed by chemists for removing coloring-matter 
from alkaloids. It was formerly regarded as an excellent fil- 
tering medium for drinking-water, but it has been shown to be 
unsafe for this purpose, since by adding phosphates and nitrates 
to the water it actually favors the development of bacteria. 

OTHER GERMICIDES, ANTISEPTICS, AND 
DEODORIZERS. 

Silver Compounds (see pp. 369-374). — The salts of silver 
are powerful germicides. Many of the organic salts are not 



4 14 ANTIMALARIALS. 

so irritant as the nitrate, and, moreover, are not affected by 
albuminous matters or chlorids. They are used especially on 
mucous membranes. 

Bromin (see p. 454). — This substance is an energetic dis- 
infectant, but it is rarely used on account of its destructive and 
intensely irritant properties. A weak solution (1 1400), how- 
ever, is occasionally employed as a deodorizer for cisterns, 
trenches, slaughter-houses, etc. 

Ferrous Sulphate (see p. 294). — This salt is a very feeble 
disinfectant. It is sometimes used as a deodorizer for middens, 
cesspools, etc. 

Volatile Oils. — Many of the volatile oils, while they are 
not actively germicidal, have considerable power as antisep- 
tics. The oils of sandalwood, copaiba, and cubeb (see pp. 
230-232) are largely used as genito-urinary antiseptics. 

Methyl-blue (Pyoktanin). — This substance, like many of 
the anilin dyes, has some power as an antiseptic, but very little 
as a germicide. A solution of I : 1 000 has been used with 
some success in ophthalmic surgery. 

Methylene-blue (see p. 420). — This compound, in doses 
of from 1-3 gr. (0.06-0.2 gm.), has been used as a urinary anti- 
septic in gonorrhea. It is also of value as an antimalarial, 
though it is decidedly inferior to quinin. 

Acetanilid (see p. 347). — This compound has been used to 
some extent as a substitute for iodoform in the treatment of 
burns and ulcers. 



ANTIMALARIALS. 

Antimalarials are drugs that exert a curative influence in 
malaria by acting destructively upon the specific parasites pres- 
ent in the blood. The alkaloids of cinchona, especially quinin, 
are by far the most important members of this class. Methylene- 
blue and Warburg's tincture, while they have some virtue, do 
not approach quinin in efficacy. Arsenic, though useful in 
correcting the anemia caused by the parasites, does not appear 
to have any special action. Many other drugs have been rec- 
ommended as antimalarials, but they have not been found 
trustworthy. 



CINCHONA. 415 

CINCHONA, U. S. P. 

(Peruvian Bark.) 

Cinchona is the bark of Cinchona Calisaya and other 
species oi^ cinchona, tall evergreen trees indigenous in South 
America, and at present largely cultivated in India, Java, and 
Jamaica. Its activities depend upon a number of alkaloids, 
the most important of which are quinin, quinidin, cinchonin, 
and cinchonidin. To be up to the official standard the bark 
should contain at least 5 per cent, of total anhydrous cinchona 
alkaloids and not less than 4 per cent, of anhydrous ether — 
soluble alkaloids (quinin, quinidin, and cinchonidin). 

In addition to its alkaloids, cinchona contains quinic acid, 
quinovic acid, and quinotannic acid. 

Preparations. Dose. 

Fluidextractum Cinchonas, U. S. P. . . . £-1 fl. dr. (2.0-4.0 c.c). 

Tmctura Cinchonas, U. S. P 1-2 fl. dr. (4.0-8.0 c.c). 

Tinctura Cinchonas Compositae, U. S. P. 
(Huxham's Tincture: red cinchona, 10; 
bitter orange-peel, 8 ; serpentaria, 2 ; gly- 
cerin, 7.5 ; water, 7.5 ; alcohol, to make 
100) 1-4 fl. dr. (4.0-15.0 c.c). 

The following alkaloids and their salts are also employed 
medicinally : 

Quinina, U. S. P ] 

Quininae Sulphas, U. S. P 

Quinina? Bisulphas, U. S. P 

Quininae Hydrochloridum, U. S. P. . 
Quininae Hydrobromidum, U. S. P. . 

Quininae Salicylas, U. S. P 

Quininae Tannas 

Quininae Valeras 

Quininae Dihydrochloridum 1-30 gr. (0.06-2.0 gm.). 

Quininae Dihydrochloridum Carbamidata (qui- 
nin and urea hydrochlorid) I-20 gr. (0.06-2.0 gm.). 

Oleatum Quininae, U. S. P. (25 per cent.). 

Cinchoninae Sulphas, U. S. P "I .«,«,„./««£«« \ 

Cinchonidinae Sulphas, U.S.P } 1-30 gr. (0.06-2.0 gm.). 

Cinchonidinae Salicylas i-io gr. (0.06-0.6 gm.). 

Euquinin (an ethyl-carbonic ester of quinin) 5-60 gr. (0.3-4.0 gm.). 

Quinin also enters into iron and quinin citrate, bitter wine 
of iron, syrup of the phosphates of iron, quinin, and strych- 
nin, compound syrup of hypophosphites, glycerite of the phos- 
phates of iron, quinin, and strychnin, elixir of iron, quinin and 
strychnin phosphates, and Warburg's tincture. 

Quinin is the most important alkaloid of cinchona, and 
represents very largely its active properties. 



r 1-3° g r - (0.06-2.0 gm.). 
10 gr. (0.06-0.6 gm.). 



4 1 6 ANTIMALARIALS. 

QUININA, U. S. P. 

(Quinin.) 

Quinin occurs in the form of a white, flaky, amorphous or 
crystalline powder, odorless, and of an intensely bitter taste. 
It is almost insoluble in water, but is readily soluble in acidu- 
lated water, alcohol, and ether. 

Physiologic Action. — In large doses (20.0 gr. — 1.3 gm.) 
quinin causes a feeling of fulness in the head, ringing in the 
ears, deafness, headache, and sometimes dimness of vision. 
The term cinchonism is applied to this group of symptoms. 
Toxic doses may cause in addition circulatory weakness, dysp- 
nea, delirium, stupor, convulsions, and coma. 

Although alarming symptoms have been produced by over- 
doses of quinin, it is very doubtful whether in a human being 
death has ever resulted directly from the use of the drug. 

Circulatory System. — Small doses do not materially affect 
the circulation, but very large doses decrease the force and 
frequency of the pulse by directly depressing the heart or its 
contained ganglia. 

Nervous System. — Toxic doses congest the brain, and prob- 
ably first stimulate and then depress the cerebral and spinal 
centers. The tinnitus aurium and deafness occurring in cin- 
chonism are doubtless the result of an intense congestion of 
the middle ear and labyrinth. In rare instances, apparently 
owing to chronic inflammation of the auditory passages or to 
hemorrhage into the labyrinth, the deafness has been permanent. 
Recent studies tend to show that quinin amblyopia results di- 
rectly from the toxic effects of the drug on the ganglion-cells 
of the retina, and not, as was formerly supposed, from con- 
striction of the retinal arteries and secondary changes in the 
optic nerves. Permanent blindness from quinin is exceedingly 
rare. 

Respiratory System. — Respiration is not affected by quinin 
except in poisoning, and then it may be slow and labored from 
depression of the center in the medulla. 

Alimentary Canal. — In small doses it whets the appetite 
and stimulates gastric peristalsis. Large doses have an irritant 
effect and sometimes excite nausea and vomiting. 

Uterus. — Quinin will sometimes intensify labor-pains when 
they are inefficient owing to weakness or fatigue. The con- 
tractions induced by it are less prolonged than those following 
the use of ergot, and are probably caused by the direct action 
of the drug on the uterine muscle. It does not seem capable 
of originating labor-pains and acting as an abortifacient. 



CINCHONA. 417 

Blood. — As Binz originally noted, quinin, when added to 
freshly drawn blood, arrests the ameboid movement of the 
white cells. Moreover, when applied in very dilute solution to 
the exposed mesentery of a frog, it suspends, almost immedi- 
ately, the migration of the leukocytes. These effects are 
ascribed to the toxic action that the drug exercises on all forms 
of undifferentiated protoplasm. Drawn blood, when mixed with 
quinin, loses in oxidizing power, as shown by its failure to 
strike a blue color with guaiac in the presence of turpentine 
and to decolorize indigo by transforming it into isatin. 

Metabolism. — Under the influence of quinin there is a con- 
siderable falling off in the nitrogenous excretion, and as this 
continues for some time after the withdrawal of the drug, it 
would seem to be due to a retardative effect upon metabolism. 

Temperature. — In health the bodily temperature is not ap- 
preciably influenced by quinin ; in febrile states, however, large 
doses exert a pronounced antipyretic effect, which is thought 
to be due to an inhibition of metabolism, in consequence of 
which heat-production is diminished. 

Absorption and Elimination. — Quinin is absorbed chiefly 
from the stomach, and is eliminated for the most part by the 
kidneys. Under favorable conditions it enters the blood very 
quickly, and traces of it may be found in the urine within 
twenty minutes after its ingestion. Its elimination, however, 
does not keep pace with its absorption, and after large doses, 
several days may elapse before all of it has left the body. It 
is excreted very largely unchanged, but a small part appears 
to be converted in the tissues into dihydroxyl-quinin. 

Action on Lower Organisms. — Quinin is not an active ger- 
micide, although it is very destructive to certain protozoa, like 
the ameba and the hematozoon of malaria. 

It is, however, an energetic antiseptic, and, in the proportion 
even of 1 : 800, it inhibits the growth of bacteria in fluids con- 
taining considerable organic matter. 

Untoward Effects. — Idiosyncrasies to quinin are not in- 
frequently encountered. In some individuals a dose of from 
2-3 gr. (0.1-0.2 gm.) will cause intense cinchonism. Impair- 
ment of vision is fortunately rare, and has generally been pro- 
duced by very large doses. Quinin rashes are not uncommon ; 
of 60 cases analyzed by Morrow, 38 were erythematous, 12 
urticarial, 5 purpuric, and 2 vesicular and bullous. Irritability 
of the bladder and urethra is occasionally noted. 

Therapeutics. — Owing to its destructive action on the 
parasites of malaria, quinin is to be regarded as a specific in this 
27 



4 1 8 ANTIMALARIALS. 

disease. The quartan and tertian hematozoa readily succumb 
to it, but the estivo-autumnal hematozoa are more resistant, 
especially when in the crescentic or ovoid form. In ordinary 
intermittent fever doses of from 15-30 gr. (1.0-2.0 gm.) a day 
will generally arrest the paroxysms within three or four days. 
The drug is most effective when its administration is so timed 
that the maximum amount shall be in the blood during the 
paroxysm — that is, while sporulation is in progress. Thus, 
the daily dose may be divided into smaller doses of 5 gr. 
(0.3 gm.) each, the first being given about eight hours and the 
last not less than three hours before the expected chill. When, 
however, the patient is not seen until within a short time of the 
expected paroxysm, a single large dose should be given at 
once. The remedy should be continued in full doses until the 
paroxysms fail to appear, and then gradually withdrawn over a 
period of several weeks. The administration of a laxative 
dose of calomel as a preliminary measure increases the efficacy 
of the quinin, probably by facilitating its absorption. During 
convalescence arsenic may be advantageously associated with 
the quinin. 

In estivo-autumnal fever large doses — 30-40 gr. (2.0-2.6 gm.) 
a day — are usually required. In pernicious malarial fever the 
patient should be cinchonized as quickly as possible by inject- 
ing at once into the tissues of the thigh or buttock about 30 
gr. (2.0 gm.) of a soluble salt of quinin like the dihydro- 
chlorid. 

Whether the administration of quinin is at times responsible 
for the occurrence of hemoglobinuria in malarial subjects, as 
was first suggested by Veretas in 1858, is still a mooted ques- 
tion. Even if the affirmative be true, there does not seem 
to be any good reason for withholding the drug in cases 
of hemoglobinuria when malarial parasites can be detected in 
the blood. Bastianelli has summed up the matter in the fol- 
lowing rules: If hemoglobinuria occurs during the par- 
oxysms and parasites are found, use quinin ; if parasites are 
not found, do not use quinin ; if quinin has been used before 
the hemoglobinuria begins and there are no parasites, discon- 
tinue the quinin. 

Quinin is not only a curative remedy in malaria, but also a 
valuable prophylactic agent. Daily doses of from 4-8 gr. 
(0.26-0.5 gm.) will generally prevent the incidence of the dis- 
ease in persons living in malarial regions. The drug does not 
afford immunity from the disease, but prevents the develop- 
ment of the parasites. 



CINCHONA. 419 

Quinin, in doses of from 1-3 gr. (0.06-0.2 gm.), has long 
been used as a general tonic in states of lowered vitality follow- 
ing acute disease or brought on by overwork. In such cases 
it may be combined conveniently with iron and strychnin. 
Small doses are thought to be of some value also in acute in- 
fections, like septicemia, diphtheria, and influenza. It is possi- 
ble that the drug owes its efficacy in these diseases, at least in 
part, to its retarding influence on the tissue changes. Warm 
rectal injections of the alkaloid (1 : 5000 to 1 : 2000) have been 
found of service in amebic dysentery. In whooping-cough 
moderately large doses are sometimes useful in lessening the 
severity and frequency of the paroxysms, but it is not known 
how the drug acts. Quinin has been recommended in neu- 
ralgia and in headache, when the attacks are more or less 
periodic, but unless these affections can be traced to a malarial 
origin, the drug is not likely to do good. 

The use of quinin as an antipyretic (see p. 352) is almost 
obsolete. In doses of from 20-30 gr. (1.3-2.0 gm.) it un- 
doubtedly has a pronounced effect upon high temperature, 
especially if it be given a few hours before a natural remission 
is expected to occur ; but when drugs must be used at all as 
antipyretics, the preference should generally be given to the 
coal-tar derivatives, on account of the promptness and certainty 
of their action and their comparative freedom from disagreeable 
by-effects. 

Quinin (10-15 gr. — 0.6-1.0 gm.) is sometimes of value as an 
ecbolic (see p. 256) in the first stage of labor when the pains 
are infrequent and inefficient, owing to simple uterine inertia. 

Contraindications. — The chief contraindications are men- 
ingitis and acute middle-ear disease. It should be administered 
cautiously when acute inflammation of the genito-urinary tract 
exists. There is some evidence to show that the drug some- 
times acts unfavorably in epileptics in increasing the number 
of seizures. Of course, quinin should be withheld from pa- 
tients in whom, owing to idiosyncrasy, it has previously caused 
grave symptoms. 

Administration. — Under ordinary circumstances quinin 
should be given by the mouth. It may be prescribed in cap- 
sules, cachets, freshly made pills, or in solution. The last 
method of prescribing it, however, is objectionable on account 
of its intensely bitter taste. Old pills skould be avoided, since 
they are liable to escape from the stomach before the alkaloid 
has been liberated and absorbed. The sulphate, though it is 
most commonly selected, is not so eligible as the more soluble 



420 ANTIMALARIALS. 

dihydrochlorid (4 parts of water), bisulphate (8.5 parts of 
water), and hydrochlorid (18 parts of water). If the sulphate 
be used, it should be rendered soluble by associating with it 
a few drops of one of the mineral acids. 

To children the drug may be given suspended in syrup of 
yerba santa, syrup of chocolate, or elixir of licorice. The tan- 
nate, while it has less than half of the alkaloidal strength of 
the sulphate, is only slightly bitter, and may, therefore, be 
given to children in the form of chocolates. Euquinin is a 
tasteless and insoluble preparation, somewhat more active than 
the tannate. 

Quinin is absorbed very imperfectly from the bowel, but for 
young children it may be prescribed in the form of supposi- 
tories, each containing 2 or 3 gr. (0.13-0.2 gm.) of a soluble 
salt like the dihydrochlorid. 

For hypodermic use only the most soluble salts should be 
used, such as the dihydrochlorid, carbamidated dihydro- 
chlorid, or bisulphate. If the bisulphate be chosen, the solu- 
tion should be slightly acidulated with tartaric acid to prevent 
the precipitation of the salt by the alkaline juices of the tissues. 
The injections should be intramuscular rather than subcutane- 
ous, and should be given with the most thorough antiseptic 
precautions. 

Bacelli has reported excellent results in pernicious malarial 
fever from the employment of intravenous injections of quinin. 
He recommends the following solution : 

Be Quininse hydrochloride gr. xv (1.0 gm.); 

Sodii chloridi, gr. xij (0.8 gm.) ; 

Aquae destillatae, f giiss (9.2 c.c). M. 

Sig. Boil and filter; inject while still warm. 

Of the fluid preparations of cinchona, the compound tinc- 
ture is the most effective. It is rarely used, however, except 
as a restorative. 

Incompatibles. — Alkalis, tannic acid, iodids, and spirit of 
nitrous ether. 

Cinchonin and Cinchonidin. — The action of these alka- 
loids is very similar to that of quinin, but it is much less powerful. 

METHYLTHIONINiE HYDROCHLORIDUM, 
U. S. P. 

(Methylthionin Hydrochlorid; Tetramethylthionin Hydrochlorid; Methylene- 
blue; CHjgNaSCl.) 

Methylene-blue is a complex anilin derivative, occurring in 
dark -blue crystals or as a bronze-like powder, slightly soluble 



METHYLTHIONIN^l HYDROCHLORIDUM. 42 1 

in water and in alcohol. The dose is from 1-4 gr. (0.065- 
0.26 gm.). Its action has not been carefully studied. When 
taken by the mouth or injected subcutaneously, it enters the 
blood and soon reappears in the secretions, especially in the 
urine, to which it imparts an intensely blue or greenish-blue 
color. Large doses irritate the stomach and also excite fre- 
quent and painful micturition. Achard and Castaigne, having 
found that in cases of renal disease the elimination of methyl- 
ene-blue when injected intramuscularly is retarded as com- 
pared with the elimination in a normal subject, suggested that 
the degree of permeability of the kidneys might be determined 
by using as a criterion the time intervening between the injec- 
tion of the drug and its reappearance in the urine. Subse- 
quent studies, however, showed that this method, while of 
some value in determining the presence of interstitial nephritis, 
could not be depended upon in cases of parenchymatous 
nephritis. 

The fact that methylene-blue is one of the best stains for 
the hematozoa of malaria suggested its use as a remedy in 
this disease. While it undoubtedly has some virtue, its effi- 
cacy is distinctly inferior to that of quinin. It may be used 
with advantage, however, when, owing to an idiosyncrasy, 
quinin cannot be taken. Berthier has found it useful in dysen- 
tery ; he recommends warm injections containing from ij— 3 
gr. (0.1-0.2 gm.) to a pint or quart (0.5-1.0 L.). Flint found 
it of service in cases of filariasis, but in a case studied by 
Henry it was without effect. The drug appears to be of some 
value as an antiseptic in inflammatory diseases of the genito- 
urinary tract, especially in gonorrhea. 

The strong affinity shown by Ehrlich to exist between the 
axis-cylinders of nerves and methylene-blue prompted the use 
of the drug as an analgesic and a sedative. It has been em- 
ployed as an analgesic by Lemoine, Klemperer, and others 
with asserted good results in neuralgia, sciatica, and migraine, 
and as a sedative by Bodoni and others in various forms of 
insanity characterized by excitement. 

Methylene-blue may be administered by the mouth or sub- 
cutaneously. The former is the better method, as the injections 
are quite painful. It should be prescribed in pills or capsules, 
combined with half its weight of powdered nutmeg, the latter 
serving to prevent gastric disturbances and irritation of the 
bladder. If it be given hypodermically, the solution should 
first be sterilized by boiling, otherwise abscess is liable to occur. 
Patients should always be warned of the discoloration of the 
urine caused by the drug. 



422 ANTHELMINTICS. 

WARBURG'S TINCTURE. 

(Antiperiodic Tincture.) 

Warburg's tincture was for a time a proprietary preparation, 
but in 1875 the originator himself made known its composi- 
tion. As a number of the ingredients recommended by War- 
burg are no longer obtainable, the remedy is at the present 
day prepared after a somewhat simpler formula than the origi- 
nal one. Each fluidounce (30.0 c.c.) contains : Quinin, 10 
gr. (0.65 gm.) ; rhubarb and angelica seed, of each, 3-I- gr. (0.2 
gm.) ; elecampane, saffron, fennel, and extract of aloes, of each, 
l i S T - ( 0<I g m -) i gentian, zedoary, cubeb, myrrh, white agaric, 
and camphor, of each, -J gr. (0.05 gm.). The value of this 
tincture as an antimalarial, especially in the severer forms of 
estivo-autumnal fever which prevail in tropical countries, ap- 
pears to be well established. To be effective it is necessary 
that it should produce copious diaphoresis, and to this end it 
should be given in doses of half an ounce (15.0 c.c), undiluted, 
all drink being withheld from the patient. Playfair has found 
it very efficacious as an antipyretic in protracted cases of 
puerperal sepsis. 



ANTHELMINTICS. 

Anthelmintics or vermifuges are drugs which destroy or ex- 
pel intestinal worms. The principal members of this class are 

For tape-worms : 

Aspidium. Pumpkin-seed. 

Pomegranate. Kamala. 

Kousso. Oil of turpentine. 

Chloroform. Thymol. 

For round-worms : 

Santonin. Spigelia. 

Chenopodium. 

For seat- worms or pin- worms : 

Santonin or Spigelia by the mouth and one of the follow- 
ing drugs by rectal injection : 

Quassia. Vinegar. 

Lime-water. Sodium chlorid. 

Tannin. 
For ankylostomes or hook-worms : 

Thymol. Betanaphthol. 



ASPIDIUM— GRAN A TUM. 42 3 

Anthelmintics are most effective when preceded and fol- 
lowed by purges. In the case of the tape-worm it is advisable 
that the patient should fast, or, at least, be restricted to very 
small quantities of liquid food for twenty-four hours before 
taking the anthelmintic. 

ASPIDIUM, U. S. P. 

(Male Fern; Filix-mas.) 

Aspidium is the rhizome of Dryopteris Filix-mas and of 
Dryopteris marginalis, ferns growing in North America, Eu- 
rope, and Asia. It contains a fixed oil, a volatile oil, resin, 
filicic acid, and a number of neutral bodies, the chief of which 
is aspidin. Of these, filicic acid and aspidin are probably the 
most active constituents. 

Preparation. Dose. 

Oleoresina Aspidii, U. S. P \-i fl. dr. (2.0-4.0 c.c). 

Physiologic Action and Therapeutics. — In overdoses 
aspidium is an energetic poison, producing abdominal pains, 
vomiting and purging, vertigo, headache, increased reflex 
activity, tonic spasms, collapse, and coma. Temporary or 
permanent blindness has also been present in many of the 
cases. Of 78 cases of poisoning by male-fern collected by 
Sidler-Huguenin, in 12 death occurred, and in 18 there was 
lasting impairment of sight in one or both eyes. According 
to Okamoto, microscopic examination of the eyes of poisoned 
dogs shows degenerative changes in the optic nerves. 

Aspidium is perhaps the most generally useful remedy for 
tape-worm. A dram (4.0 c.c.) of the oleoresin may be given 
in emulsion or in capsules at bedtime, and followed in the 
morning by a saline purgative. Castor oil should not be used, 
as it is believed to increase the toxicity of aspidium by favor- 
ing the absorption of its active constituents. 

GRANATUM, U. S. P. 

(Pomegranate.) 

Pomegranate is the bark of the stem and root of Punica 
Granatum, a small tree indigenous in Southwestern Asia, and 
cultivated in most subtropical countries. It contains, in addi- 
tion to a large quantity of tannin, a number of alkaloids, the 
chief of which is punicin or pelletierin. The latter represents 
very largely the anthelmintic properties of the bark, and occurs 
as a colorless oily liquid, capable of uniting with acids to form 



424 ANTHELMINTICS. 

crystalline salts* The official pelletierin tannate (Pelletierince 
Tannas) is a mixture in varying proportions of the tannates of 
several alkaloids contained in the bark. It may be given in 
doses of from 5-8 gr. (0.3-0.5 gm.). 

Preparation. Dose. 

Fluidextracti Granati, U. S. P 1-2 fl. dr. (4.0-8.0 c.c). 

Physiologic Action and Therapeutics.— Locally, pom- 
egranate is astringent. Internally, large doses of the bark or 
of the alkaloid may cause headache, vertigo, dimness of vision, 
nausea, vomiting, and extreme muscular weakness. The last 
symptom is said to result from paralysis of the peripheral ends 
of the motor nerves. 

Pomegranate is a reliable remedy for tape-worrn y ranking 
next to aspidium in efficiency. The fluidextract or a decoction 
(1 oz-31.0 gm.) is sometimes used, but these preparations are 
very unpalatable and less certain in their action than the alka- 
loid. Adjuvant treatment is necessary as in the case of the 
other teniacides. 

CUSSO,U. S. P. 

(Kousso; Brayera.) 

Cusso is the female inflorescence of Hagenia abyssinica, an 
ornamental tree growing in the mountainous districts of Abys- 
sinia. A neutral body, kosotoxin, is probably the active princi- 
ple. The dose of the powdered drug is from 6-8 dr. (24.0-31.0 
gm.). Koussein, which is probably an impure preparation of 
kosotoxin, may be given in doses of from 15-30 gr. (1.0-2.0 
gm.). The crystalline body known as kosin is inactive. 

Preparation. Dose. 

Fluidextractum Cusso 2-6 fl. dr. (8.0-22.0 c.c). 

Therapeutics. — Cusso, provided it be fresh, is a powerful 
teniacide. The fluid extract is less efficacious than an infusion 
in which the powdered flowers have been allowed to remain ; 
both preparations, however, are unpalatable and are apt to 
excite nausea and vomiting. Koussein is an active prepara- 
tion, but costly. It is readily taken, especially if dispensed in 
cachets. Cusso does not usually require the assistance of a 
purgative, but one should be given if the bowels do not move 
within six or eight hours. 



PEPO — KAMALA — SANTONINUM. 425 

PEPO, U. S. P. 

(Pumpkin-seed.) 

Pepo is the seed of the common pumpkin, Cucurbita Pepo. 
It contains a fixed oil and a resin, the latter probably being the 
active principle. The dose is from 1-3 ounces (31.0 gm.-Q3.o 
gm.). 

Pumpkin-seed is a perfectly safe, but somewhat uncertain, 
remedy for tape-worm. It is usually prescribed in the form 
of an emulsion, made by beating the decorticated seeds into a 
paste, adding sugar, and diluting with water or milk. It 
should be taken in the morning on an empty stomach, and fol- 
lowed in two or three hours by castor oil. 

KAMALA. 

(Rottlera.) 

Kamala is a brownish-red, tasteless powder, consisting of the 
minute glands and hairs obtained from the surface of the cap- 
sules of Mallotus philippinensis , a small tree growing in wes- 
tern Asia and the neighboring islands. It contains several 
resinous principles, one of which occurs in yellow needles and 
is known as rottlerin. The dose of the powder is from 1—2 
dr. (4.0-8.0 gm.). 

Therapeutics. — Kamala has been highly spoken of as a 
teniacide by East Indian surgeons. It is rarely employed in 
this country. It is best given suspended in syrup or honey. 
A purgative is seldom required after it, as the drug itself 
causes considerable intestinal irritation and diarrhea. 

SANTONINUM, U. S. P. 

(Santonin.) 

Santonin is a neutral principle obtained from santonica, or 
Levant wormseed {Artemisia pauciflora), a perennial shrub 
growing in Turkestan. It occurs in white, shining prisms, 
odorless, and of a slightly bitter taste. It is nearly insoluble 
in water, but readily so in alkaline solutions. The dose for a 
child is ^-1 gr. (0.016-0.065 gm.); for an adult, 1-5 gr. 
(0.065-0.3 gm.). 

Preparation. Dose. 

Trochisci Santonini, U. S. P. (each troche 

contains £ gr. — 0.03 gm.) 1-5 troches. 

Physiologic Action and Therapeutics. — In therapeu- 
tic doses santonin produces no special symptoms except an 
intensely yellow coloration of the urine and sometimes yellow 
vision, or xanthopsia. The last symptom is probably the 



426 ANTHELMINTICS. 

result of a specific action of the drug on the nerve-centers or 
retina, although some investigators believe it to be due simply 
to staining of the humors of the eye. The fate of santonin in 
the body is not definitely known. A part is undoubtedly ab- 
sorbed, probably as a santoninate, is largely oxidized in the 
tissues, and finally excreted in the form of oxysantonins. 

Santonin poisoning is characterized by yellow vision, myd- 
riasis, vertigo, tremors, unconsciousness, and violent convul- 
sions, first epileptiform and then tetanic. Nausea and vomiting 
have been observed in some instances. When death results it 
is usually through asphyxia. The convulsions are due to 
stimulation of the motor centers — first the cerebral and then 
the spinal. 

Santonin is used almost exclusively as a remedy for the 
round-worm. It may be prescribed in lozenges or in powders, 
mixed with a few grains of sugar. A good plan is to give the 
drug morning and evening and to follow it next day by a brisk 
cathartic like castor oil or calomel. For a child under two 
years the dose should never be more than \ gr. (0.03 gm.) ; 
and for a child under five years, never more than 1 gr. (0.065 
gm.). Santonin has been recommended in certain other affec- 
tions, notably in amaurosis, amenorrhea, incontinence of urine, 
and epilepsy, but its claims to confidence are very doubtful. 

SPIGELIA, U. S. P. 

(Pinkroot.) 

Spigelia is the rhizome and roots of Spigelia marilandica, a 
perennial herb growing in the Southern United States. It con- 
tains a volatile oil, tannin, a bitter principle, and an alkaloid 
known as spigelin. 

Preparation. Dose. 

Fluidextractum Spigelise, U. S. P \-z fl. dr. (2.0-8.0 c.c). 

Therapeutics. — Spigelia is a very efficient, and, if reason- 
able care be used in its administration, a perfectly safe remedy 
for the round-worm. Toxic doses produce excitement, flushing 
of the face, swelling of the eyelids, dilatation of the pupils, 
dimness of vision, and, finally, stupor. It should always be 
administered in association with a purge. 

CHENOPODIUM. 

(American Wormseed.) 

Chenopodium is the fruit of Chenopodium anthelminticum, a 
perennial herb indigenous in Central and South America, and 
naturalized in the United States. The active principle is a 



OTHER ANTHELMINTICS. 427 

volatile oil (Oleum Chenopodii, U. S. P.), the dose of which is 
from 3-10 min. (0.2-0.6 c.c). 

Therapeutics. — Chenopodium is a reliable vermicide for 
round-worms — less pleasant to take, however, than santonin or 
spigelia. The oil, which is almost exclusively used, should be 
given on sugar or in an emulsion three times a day, and fol- 
lowed by a brisk purgative every other day. 

OTHER ANTHELMINTICS* 

Oil of Turpentine (see p. 236). — This drug was formerly 
much used as an anthelmintic for tape-worm, but it has been 
almost entirely supplanted by remedies that are more agree- 
able and quite as efficacious. If it be selected as a teniacide, it 
should be given in doses of half an ounce (15.0 c.c.) combined 
with an equal amount of castor oil. 

Chloroform (see p. 123)0 — This drug, in doses of ±-1 fl. dr. 
(2.0-4.O c.c), has been used to a limited extent as a teniacide, 
but it is unreliable. 

Quassia (see p. 175). — Rectal injections containing quassia 
are very efficacious in oxyures, or pin-worms. To secure the 
best results the lower bowel should first be thoroughly emp- 
tied by means of a soap-and-water enema, after which 2 
ounces (60.0 c.c.) of a cold infusion of quassia (1 oz. to 1 pint 
— 31.0 gm.— 0.5 L.) should be slowly injected. As the parasites 
often occupy the cecum and small intestine as well as the rec- 
tum, it may be necessary, in some instances, in order to secure 
permanent relief, to give also by the mouth an anthelmintic 
(spigelia or santonin) with a cathartic. 

I/ime-water, Vinegar, Sodium Chlorid, and Tannin. 
— These drugs are sometimes used in the form of rectal in- 
jections to destroy pin-worms. None is quite so efficacious as 
quassia. They may be used in the following proportions : 
Lime-water, undiluted ; vinegar, 1 to 3 ; sodium chlorid, 1 dr. 
(4.0 gm.) to a pint (0.5 L.); tannin, \ dr. (2.0 gm.) to a pint 

(0.5 14 

Thymol (see p. 392). — This drug, in doses of 30 gr. (2.0 
gm.) for adults, or 8—15 grains (0.5-1.0 gm.) for children, re- 
peated in two hours, one day a week, a saline purge being ad- 
ministered before and after the treatment, is a valuable remedy 
in uncinariasis or hook-worm disease. It has been used also 
with some success as an anthelmintic against the tape-worm, 
especially the Dibothriocephalus latus and the common round 
worm. 

Betanaphthol (seep. 394). — This drug, used in the same 
way as thymol, but in doses half as large, has been found very 
effective in uncinariasis or hook-worm disease. 



428 ANTITOXINS AND VACCINES. 



ANTITOXINS AND VACCINES. 

Our knowledge of the subject of serum-therapy is the out- 
growth of the studies upon immunity. 

Immunity. — The inborn insusceptibility of an individual to 
a disease to which others are commonly susceptible constitutes 
natural immunity. Immunity the result of changes which 
have taken place in the body during the life-time of the in- 
dividual is termed acquired immunity. The latter may be the 
result of disease naturally contracted {unintentional immunity) ■; 
or it may be the result of injections of specific micro-organisms 
or their spores in an attenuated form, or of minute doses of 
virulent, specific micro-organisms, or of the dead bacteria with 
their contained toxins, or of the serum of an animal that has 
been previously protected from the disease by one of these 
methods (intentional or artificial immunity). 

As Ehrlich, Calmette, and others have shown, the power to 
confer immunity is not confined solely to bacterial toxins, but 
is shared also by other organic poisons, like ricin (from castor- 
oil beans), abrin (from jequirity seeds), and the venom of 
poisonous serpents. The study of the mechanism of im- 
munity has scarcely reached beyond the hypothetical stage. 
Pasteur reasoned that a second infection was impossible in 
many diseases, because in the first infection the bacteria had 
used up substances that were necessary to their growth. This 
theory at once became untenable when it was shown that the 
metabolic products of bacteria were as powerful in conferring 
immunity as the bacteria themselves. Chauveau conceived 
the idea that the bacteria left material in the body which ren- 
dered the tissues unsuitable for subsequent infection. A seri- 
ous objection, however, to this theory is the fact that the 
blood-serum of the animal artificially protected is in many 
cases a good culture-medium for the special bacteria con- 
cerned. Metschnikoff believes that immunity depends entirely 
upon cellular activity (phagocytosis). He originally taught 
that the main factor in the process was the capacity of the 
leukocytes and of certain other cells to ingest and destroy the 
bacteria. The discovery of the immunizing power of specific 
sera necessitated a modification of this view, and this distin- 
guished observer now teaches that the injection of soluble 
protective substances exerts an " educational " or stimulating 
effect upon the phagocytes, in consequence of which their 
activity is so intensified that they ultimately become invincible. 
He further asserts that any bactericidal power that the body- 
fluids may possess is to be attributed to substances derived 



ANTITOXINS AND VACCINES. 429 

from the stimulated leukocytes. That phagocytosis is an ex- 
tremely important factor in the establishment of immunity is 
generally admitted ; that it is the sole factor, however, is highly 
improbable. Pfeiffer demonstrated that cholera vibrios injected 
into the peritoneal cavity of the artificially immunized guinea- 
pig were destroyed without the aid of the phagocytes. The 
humoral theory evolved from the studies of Nuttal, Fliigge, 
Behring. and others is well grounded on experimental data. 
This theory attributes immunity to the power of the extra- 
cellular fluids, especially of the blood-serum, to neutralize the 
poisons made by bacteria or to destroy the bacteria themselves. 
These antitoxic or bactericidal powers are believed to be due, 
however, to substances derived from the cells. Those substances 
which neutralize toxins are known as antitoxins, and those 
which disintegrate and dissolve the bacteria are known as bac- 
teriolysins. In certain infections, like diphtheria and tetanus, 
immunity is chiefly antitoxic, while in others, like cholera and 
typhoid fever, it is mainly antibacterial. 

The manner in which these protective bodies act has not yet 
been clearly explained, but the " lateral-chain " theory of Ehr- 
lich is highly suggestive. This theory presupposes that the 
protoplasm of the cells contains complex molecules having a 
comparatively stable central group of atoms, to which are at- 
tached much less stable lateral chains of atoms. 

These lateral chains have the power of fixing or " anchoring" 
such toxins for which they have an affinity, a group of atoms 
of the cell entering into combination with a group of the toxin. 
These are designated haptophore groups. In addition to its 
haptophore group the toxin contains a toxaphore group, which 
carries its toxic properties, but this toxaphore group cannot 
act upon the cell until the toxin has been anchored to the cell 
by a union of the haptophore groups. The haptophore groups 
of the cells, which are also known as receptors, can unite only 
with the haptophore groups of toxins for which they have a 
special affinity ; hence a toxin may prove harmless for the 
want of a receptor having an affinity for it (natural immunity). 
In anchoring the haptophores of the toxin by means of its 
receptors the cell suffers a defect, which, according to definite 
natural laws, is repaired by a new formation of receptors of 
the same functional quality. Further fixation ultimately leads 
to the formation of receptors in excess of those previously 
existing. These extra receptors, separated from the cells and 
free in the blood-plasma, are the a?ititoxi?is which unite with the 
toxins and neutralize them by preventing their union with re- 
ceptors still attached to the cells. 



430 



ANTITOXINS AND VACCINES. 



In the case of antibacterial immunity, Ehrlich holds that the 
extra receptors serve as an immune body, without which another 
body, normally present in the blood and probably derived from 
the leukocytes, termed the complement (alexin of Buchner), 
cannot exert any bactericidal influence. The immune body, 
which is also known as the amboceptor, has two haptophore 
groups, one having an affinity for the complement {comple- 
mentopkilic), the other having an affinity for the bacterium 
{cytophilic). After the complement has become anchored to 
the complementophilic group of the amboceptor it is able to 
bring about the solution of the bacterium (bacteriolysis). 

The subject of artificial immunity is closely related to that 
of serum-therapy, inasmuch as it has been well established 
that a susceptible animal which has been rendered artificially 
immune against a certain infection is capable of furnishing a 
serum which, injected into other susceptible animals, will pro- 
tect them from a like infection, and even arrest such an in- 
fection if it is just beginning. Many pathogenic bacteria 
furnish both an antitoxin and a bacteriolysin, but usually one 
in greater proportion than the other. Thus far, decided thera- 
peutic results have been obtained only in those infections 
the bacteria of which furnish serum especially rich in antitoxin 
bodies. As antitoxins only neutralize toxins and have no power 
to undo the damage that the latter have already wrought, it is 
evident that the earlier they are administered in any infection, 
the more effective they will be. 

Another class of substances in the blood-serum apparently 
plays an important part in bacteriolysis. It has been shown 
by Wright that the leukocytes do not readily take up and 
digest bacteria unless they are aided by certain bodies in the 
plasma, which he has termed opsonins} These opsonins act 
upon the bacteria in such a way as to make them an easy prey 
to the leukocytes. The ratio between the average number of 
bacteria taken up by healthy leukocytes in a mixture of a bac- 
terial suspension with a patient's blood-serum and the average 
number taken in a mixture of the same bacteria with normal 
serum is known as the opsonic index. The latter, normally 
taken as i.o, is low in most infections. By the injection sub- 
cutaneously of measured small quantities of dead bacteria 
(vaccines or bacterins) it is possible to raise considerably the 
opsonic power of the blood-serum and so favor phagocytosis. 
Good results have been obtained from successive vaccinations 
with specific bacteria, after the method of Wright, in certain 

1 From the Greek word " opsono," I cater for. 



SERUM ANTIDIPHTHERICUM. 43 1 

cases of tuberculosis, gonorrhea, staphylococcus infections 
(furunculosis, acne), and Bacillus coli infections. 

SERUM ANTIDIPHTHERICUM, U. S. P. 

(Diphtheria Antitoxin.) 

Diphtheria antitoxin is obtained from the horse, the animal 
having been rendered artificially immune by repeated injec- 
tions extending over a period of several months, of gradually 
increasing quantities of the strongest diphtheria toxin. As the 
bacilli themselves are not injected, the horse does not become 
infected with diphtheria, but he gradually acquires a tolerance 
for the toxins of the disease and develops in his blood a sub- 
stance (antitoxin) which has the power to neutralize those 
toxins. At the proper time, when it is thought that his blood 
has acquired the requisite degree of potency, the animal is 
bled, and the serum — the part of the blood containing the 
antitoxin — is carefully separated from the clot, filtered, and 
standardized. The last procedure is accomplished by deter- 
mining the quantity of antitoxin serum required to offset the 
effects of the minimum quantity of toxin necessary to kill a 
guinea-pig in a definite time. The strength of the antitoxin is 
measured in units, a unit containing the amount of antitoxin 
required to save the life of a guinea-pig which has been injected 
with 100 fatal doses of toxin. Irrespective of the toxin in- 
jected and of the duration of the immunizing treatment, the 
serum yielded by different horses varies considerably in anti- 
toxin strength. Only a very small percentage of horses give 
more than 1000 units in a cubic centimeter. 

Therapeutics. — Diphtheria antitoxin has both preventive 
and curative power. The immunity afforded by it is but tem- 
porary, rarely lasting more than two or three weeks. The 
prophylactic dose is from 500 to 1000 units. That it is a 
powerful curative agent is evident from the fact that the mor- 
tality of diphtheria has been reduced at least 50 per cent, since 
the introduction of serum treatment. Baginsky claims that 
the mortality has fallen from 41 to 8 or 9 per cent. In 5576 
cases (moribund cases excluded) collected by the American 
Pediatric Society, mostly from the private practice of Ameri- 
can physicians, the death-rate was 8.8 per cent. 

In the laryngeal cases the figures have been reversed ; in- 
stead of a mortality of 70 per cent, or more, the recoveries 
now number 70 per cent, or more. The chances of recovery 
in all cases vary directly with the time of administration. 
The statistics of the American Pediatric Society show that if 



432 ANTITOXINS AND VACCINES. 

antitoxin is injected upon the first day the death-rate is 4.9 
per cent. ; if upon the second day, 8.6 per cent. ; if upon the 
third day, 12.7 per cent; if upon the fourth day, 22.9 per 
cent. ; and if after the fourth day, 38 per cent. In pharyngeal 
cases, if the patient is seen early, the dose should be 3000 
units ; when treatment is inaugurated rather late and the 
case is severe, the dose should not be less than 4000 units. 
Laryngeal cases require 4000 to 8000 units. Unless decided 
improvement follows the initial dose within from four to six 
hours, a second and much larger dose should be given. As 
antitoxin is practically harmless, the danger lies not in using 
too much, but in using too little. No allowance should be 
made for age, as children are more susceptible to the disease 
than adults. Antitoxin deteriorates with age, and therefore 
only fresh preparations should be used. Whether the serum 
acts indirectly through the cells (vital reaction) or directly by 
combining with the toxin (chemical reaction) is not known, 
though the weight of evidence is in favor of the latter view. 
Antitoxin is probably eliminated through all the emunctories. 
It has been found in the urine and milk. 

Administration. — As antitoxin is absorbed very slowly 
and imperfectly from the stomach, it should always be given 
subcutaneously. The needle may be inserted into the loose 
subcutaneous tissue of the pectoral region, side of the ab- 
domen, or interscapular space. Strict antiseptic precautions 
should be taken in the operation. Manipulation of the swell- 
ing to hasten the absorption of the serum is undesirable. 

Untoward Effects. — The most common of these is an ur- 
ticarial or erythematous rash. A rise of temperature of short 
duration occurs in about 20 per cent, of the cases. Joint pains, 
and even slight effusion into the joints, occur in about 6 per 
cent, of the cases. These effects are probably not produced 
by the antitoxin itself, but by other substances in the serum, 
since they may occur on injecting normal horse's serum. The 
increased frequency of complications like paralysis and al- 
buminuria since antitoxin has been used is to be attributed to 
the fact that there are more recoveries than formerly. 

OTHER ANTITOXINS AND VACCINES. 

Tetanus Antitoxin. — Tetanus antitoxin is obtained in the 
same manner as diphtheria antitoxin — that is, by inoculating 
the horse with increasing doses of tetanus toxin. The unit is 
ten times the least quantity of antitetanic serum necessary to 
save the life of a 350-gram guinea-pig for ninety-six hours 



OTHER ANTITOXINS AND VACCINES. 433 

against the official test dose of a standard test toxin furnished 
by the Hygienic Laboratory of the Public Health and Marine 
Hospital Service. The dose of the serum as a prophylactic is 
1500 units ; as an antidote, from 3000 to 6000 units. 

Unfortunately, the curative effects of tetanus antitoxin are 
not comparable to those of diphtheria antitoxin. The chief 
reasons for this are, first, the great virulence of the toxin pro- 
duced in many of the cases of tetanus, and, secondly, the ad- 
vanced stage that the disease must reach before it is recogniza- 
ble. In the case of diphtheria the diagnosis is usually made 
before much toxin has been absorbed into the system ; in the 
case of tetanus, however, diagnosis is impossible before the 
nerve-centers are fully under the influence of the toxin. Serum- 
therapy does not appear to have materially lowered the mor- 
tality in grave cases of tetanus — that is, in cases in which the 
period of incubation was less than seven or eight days ; on the 
other hand, it seems to have been of some service in the more 
chronic cases of the disease, cases in which the period of in- 
cubation ranged between eight and twenty-four days. 

In order that the antitoxin might be brought in direct con- 
tact with cells of the central nervous system, for which the 
toxin of tetanus has a great affinity, Roux and Borrell recom- 
mended the intracerebral injection of the serum, but the results 
from this method of administration have not been very en- 
couraging. Recently Jacob and others have obtained promis- 
ing results from subarachnoidal injections through a lumbar 
puncture. Despite the poor showing of the antitoxin treat- 
ment, we are of the opinion that it should be used early and 
energetically in every case of tetanus, but not to the exclusion 
of other measures known to be of benefit. As the serum, even 
in small doses, has considerable immunizing power, it should 
be given promptly as a prophylactic remedy in all suspicious 
wounds, especially in those which have become contaminated 
with garden earth, street dirt, or stable refuse. 

In the last two years the tetanus mortality incident to blank 
cartridge and cannon-cracker wounds received in Fourth of 
July celebrations has been remarkably reduced by antitoxin 
prophylaxis. 

Antistreptococcus Serum. — A serum obtained from 
horses after they have received repeated injections of strepto- 
coccus cultures has been offered as a remedy in various dis- 
eases due to streptococcus infection. These diseases include 
erysipelas, puerperal fever, septicemia, ulcerative endocarditis, 
and infective lymphangitis. Numerous cases are on record in 
which good results are attributed to the serum, but the statis- 
tics collectively do not indicate that it has had a very decided 

28 



434 ANTITOXINS AND VACCINES. 

influence in lowering the mortality of septic diseases. How- 
ever, as the serum when sterile and pure is practically harm- 
less, there seems to be no good reason for not giving it a 
thorough trial in cases of infection demonstrated by bacterio- 
logic examination to be due to the streptococcus. As yet 
there are no accurate data upon which the dosage may be 
computed, but from 20 to 30 c.c. of a reliable serum may be 
given two or three times a day so long as the fever remains 
high. As the potency of the serum is notably impaired by 
keeping, preparations more than two or three weeks old should 
not be used. 

Injections of the toxins produced by streptococci have been 
advocated in inoperable malignant tumors, but the treatment is 
not without danger and has failed to secure the indorsement 
of most surgeons. It must be admitted, however, that it has 
been apparently successful in a few instances in arresting the 
growth of sarcomatous tumors and even in effecting a cure. 

Antipneumococcic Serum. — It has been clearly demon- 
strated that the blood-serum of animals artificially immunized 
against pneumococcic infection possesses definite antitoxic prop- 
erties. A serum obtained from horses which have been 
repeatedly inoculated with cultures of pneumococci of great 
virulence has been applied to the treatment of pneumonia in 
human beings, but the reports thus far presented are to an im- 
partial observer certainly not very encouraging. According 
to a summary published by Anders, the mortality in 535 cases 
of pneumonia in which antipneumococcic serum was employed 
was 18.3 per cent. 

Antimeningococcic Serum. — In the last few years ef- 
forts have been made by a number of experimenters, notably 
by Wassermann, Jochmann, and Flexner and Jobling, to pro- 
duce a serum capable of influencing the course of cerebro- 
spinal fever. The serum of Flexner and Jobling is prepared 
by inoculating horses first with cultures of different strains of 
meningococcus heated to 6o° C. for thirty minutes and later 
with living organisms and autolysates. While the data at 
hand are too few to justify a positive opinion as to the efficacy 
of the serum, the results thus far achieved have been so encour- 
aging as to warrant a thorough trial of the remedy in all suit- 
able cases. In a series of 400 cases treated with the serum, 
the mortality, excluding the cases in which death occurred 
within twenty-four hours, was 25 per cent., which, of course, is 
very much less than the average mortality under symptomatic 
treatment. The intradural method of administration is pre- 
ferred because it brings the serum at once into direct contact 



OTHER ANTITOXINS AND VACCINES. 435 

with the active focus of infection. Introduced in this way the 
serum seems not only to cause disintegration of the meningo- 
cocci and to increase phagocytosis but also to exercise some 
antitoxic influence. From 30 to 40 c.c. of the serum are in- 
jected into the spinal canal after about an equal amount of 
cerebrospinal fluid has been withdrawn, and it is advised that 
the treatment be repeated every twenty -four hours for three or 
four days. The earlier in the attack the serum is given the 
better, of course, the outlook. 

Tuberculin and Antituberculous Serum. — In 1890 
Koch introduced as a specific remedy for tuberculosis a prepa- 
ration to which the name tuberculin was applied. This was 
subsequently shown to be an extract of the metabolic products 
of tubercle bacilli preserved in glycerin. 

Koch did not consider this original tuberculin as an immun- 
izing agent, but believed that by reinforcing the toxin already 
in the body it would increase the irritation at the seat of infec- 
tion, attract leukocytes, and, ultimately, lead to the complete 
encapsulation of the bacilli. It is now known, however, that 
Koch's tuberculin and all similar preparations act by stimu- 
lating the defensive resources of the organism and producing 
probably both antitoxic and antibacterial immunity. 

Unfortunately, tuberculin at first was applied without skill 
and often in unsuitable cases, and, consequently, it soon fell 
into discredit. During the last five or six years it has again 
been employed, especially in the sanitoriums, and has gained 
the reputation of being a valuable addition to our therapeutic 
agents when used in appropriate doses and in certain forms of 
the disease. Originally it was supposed that definite reactions 
on the part of the patient were a necessary consequence of the 
treatment, but at present it is believed that such reactions are 
absolutely harmful. The cases best adapted to tuberculin 
treatment are the chronic ones, with little or no fever. 

Of the various tuberculins introduced during the past fifteen 
years, Koch's emulsion of crushed virulent bacilli (tuberculin 
B. E.) and filtrates of human cultures, such as Deny's tuber- 
culin B. F., are now, perhaps, used most extensively. No 
matter which tuberculin is selected, the initial dose should be 
very small — y^ milligram of old tuberculin or T ^ TO milli- 
gram of filtrate B. F. or Koch's B. E. (liquid measure, not 
solid substance). The injections should be given every four 
or five days, the dose being gradually increased, but never 
large enough to cause a definite immediate reaction. If evi- 
dences of increasing sensitiveness appear, the injections should 
be stopped for a time and then commenced with smaller doses. 



436 ANTITOXINS AND VACCINES. 

In this way a high degree of tuberculin immunity is often 
reached in from six months to a year, a dose of I c.c. being 
tolerated with advantage. 

Antituberculous Serum. — Maragliano has produced a serum 
which he claims as both antitoxic and bactericidal. It is pre- 
pared by injecting into an animal the filtrate of young cultures 
of tubercle bacilli and aqueous extracts of killed virulent cul- 
tures. Some very favorable reports from the use of this serum 
have appeared, but it is too soon to form any definite opinion 
as to its efficacy. 

Antianthrax Serum. — Sclavo has prepared an antianthrax 
serum which is apparently effective, both as prophylactic and 
as a therapeutic agent, in cattle as well as in man. It is 
produced by the treatment of sheep and asses with anthrax 
bacilli subcutaneously, while at the same time or previously 
anthrax immune serum is given intravenously. According to 
Legge, the mortality in 164 cases of external anthrax in man 
treated with this serum was about 6 per cent, as compared 
with 24 per cent, in all other cases occurring in Italy. The 
serum seems to be harmless, even when used in doses of 30 
to 40 ex., or more, intravenously. 

Bubonic Plague Antitoxins and Vaccines. — In 1895 
Yersin demonstrated that animals could be successfully im- 
munized against bubonic plague by subcutaneous injections 
of sterile cultures of plague bacilli, and, further, that the blood- 
serum of animals thus artificially immuninized possessed protec- 
tive and curative properties. Serum obtained after the method 
of Yersin has been used with asserted good results in Canton, 
Amoy, Annam, Oporto, and elsewhere. Immunity conferred 
by this serum is said to last about a fortnight. Haffkine has 
prepared a prophylactic fluid which appears to be more reliable 
than Yersin's serum. It is a fluid culture of pest bacilli steril- 
ized by heating to 70 C. for one hour. Haffkine states 
that among 639,630 uninoculated persons there occurred 49,- 
433 cases of plague (j.j per cent), with 29,733 deaths (4.7 per 
cent.). Of 186,797 who had been inoculated with plague 
vaccine, 3399 (1.8 per cent.) took the disease and 814 (0.4 
per cent.) died. The immunity afforded by this vaccine is said 
to last from four to six months. 

Lustig recommends as a prophylactic a nucleoproteid ob- 
tained from dead plague bacilli, and as a remedy a serum 
obtained by treating horses with this nucleoproteid. It is 
stated that the rate of recovery under this serum in 475 cases 
was 39.36 per cent, against 20.6 per cent, of recoveries in 5962 
cases treated during the same time without serum. 

Cholera Vaccine. — It has been shown by Pfeiffer and 



OTHER ANTITOXINS AND VACCINES. 437 

others that the blood-serum of human beings who have re- 
cently recovered from attacks of cholera and of animals which 
have been artificially immunized has the property of disinte- 
grating and dissolving cholera vibrios. Unfortunately, this 
bacteriolytic serum has thus far proved unavailing when applied 
to the treatment of cholera in human beings. Haffkine, how- 
ever, appears to have been measurably successful in producing 
artificial immunity in human beings by means of subcutaneous 
injections of attenuated cholera cultures. 

Antityphoid Sertim and Typhoid Vaccine. — It has 
been shown that the blood-serum of animals artificially im- 
munized by gradually increasing doses of living or dead 
typhoid bacilli acquires specifie bacteriolytic and antitoxic 
properties. Applied to the treatment of typhoid fever, anti- 
typhoid serum has generally yielded negative results, although 
Chantemesse, of Paris, seems to have employed it with consid- 
erable success. Protective vaccination, however, by means of 
sterile cultures of the typhoid bacillus, as practised by the 
British military surgeons in South Africa and India, appears 
to have been very efficient. Leishman states that of 5473 
soldiers inoculated, only 21 were subsequently infected, with 
two deaths, while of the 6610 non-inoculated in the same regi- 
ment, 187 had typhoid and 26 died. 

Antivenene. — The studies of Sewall, Phisalix and Bert- 
rand, Calmette, Frazer, and others have established the fact 
that animals can be successfully immunized against the venom 
of poisonous snakes by being inoculated with increasing doses 
of venom, and, further, that the blood-serum of animals thus 
treated possesses both protective and antidotal properties. The 
more recent work, however, of Flexner and Noguchi and others 
has shown that antivenoms are highly if not absolutely specific, 
and to be of any practical value, therefore, a protective serum 
will have to be polyvalent. 

Antidysenteric Serum. — A serum has been prepared by 
immunizing the horse against the dysentary bacillus (Shiga- 
Kruse type), and the toxins elaborated by the bacillus, which 
is claimed to be both bactericidal and antitoxic. According to 
Shiga, the mortality in 298 cases of bacillary dysentery treated 
with this serum was 9 to 12 per cent., while it was 22 to 26 per 
cent, in 212 cases treated with drugs. 

Pollantin. — Dunbar has prepared an antiserum by treating 
the horse with irritant toxins obtained from the pollen of 
grasses. This serum is supplied in liquid and powder forms, 
the former being used mainly on the eye and the latter in the 
nose. There is no unanimity among specialists as to the 
therapeutic value of the substance in hay-fever. 



438 IRRITANTS AND COUNTERIRRITANTS. 

IRRITANTS AND COUNTERIRRITANTS. 

Irritants are substances which, when applied to the surface 
of the body, cause active hyperemia or inflammation. When 
they are applied not simply for their local action, but to in- 
fluence for the better neighboring or remote morbid processes, 
they are termed counterirritants. We have yet no clear under- 
standing of the manner in which counterirritants do good ; the 
most plausible theory, however, is that they call forth reflexly 
from the central nervous system centrifugal influences, vaso- 
motor or trophic or both, which act favorably upon local 
perturbations. 

Counterirritants which produce merely an acute hyperemia 
of the skin are known as rubefacients ; those which act more 
severely and lead to the formation of blisters are termed vesi- 
cants or epispastks ; and those which act especially on the 
ducts of the sudoriferous glands, producing a crop of pustules, 
are called pustulants. 

Counterirritation may be carried to a still greater degree of 
intensity by producing ulceration, and for this purpose it is 
now customary to use the actual cautery. This may be applied 
by means of irons of various shapes, heated to redness, or, 
better still, by means of the Paquelin cautery, in which heated 
platinum-sponge is brought to incandescence by contact with 
the vapor of naphtha or rhigolene. 

Light applications of the thermocautery are often very 
efficacious in certain deep-seated affections attended with 
severe pain, such as sciatica, chronic meningitis, arthritis, and 
locomotor ataxia. 

Still another method of producing a counterirritant effect, 
applicable to certain painful affections, is acupuncture, which 
consists in thrusting fine needles deeply into the tissues. In 
sciatica and lumbago this treatment sometimes gives brilliant 
results. The needles should be four or five inches long and 
about the thickness of a bonnet-pin. Having been sterilized, 
they should be inserted into the most painful spots to a depth 
of two or three inches, and allowed to remain for from ten to 
fifteen minutes. 

The most important rubefacients are : 

Mustard. Capsicum. 

Iodin. Chloroform. 

Oil of turpentine. Ammonia. 

Arnica. Camphor. 

Pitch. Aconite. 

Volatile oils. 



IRRITANTS AND COUNTERIRRITANTS. 439 

Rubefacients may be applied with advantage in acute con- 
gestion of the internal organs, in inflammatory affections of a 
mild type, and in functional pains. Thus they are useful in 
acute congestion of the lung, acute bronchitis, acute catarrhal 
enteritis, gastralgia, intestinal colic, muscular rheumatism, and 
neuralgia of the superficial nerves. When applied over large 
surfaces they serve also as general stimulants, and as such 
may be employed to arouse the system in collapse, shock, and 
narcotic poisoning. They may be applied in the form of plas- 
ters (mustard), stupes (oil of turpentine), liniments (chloroform, 
arnica), or pigments (iodin). 

The chief vesicant is cantharides. 

A number of the drugs classed as rubefacients (ammonia, 
mustard, chloroform, iodin), if applied in concentrated form, 
will also produce vesication, but they are never employed for 
that purpose. 

Vesicants exert a more profound and a more lasting effect 
than rubefacients. They are often of service in inflammatory 
diseases of a severe type, such as pleurisy, pericarditis, gas- 
tritis, iritis, arthritis, neuritis, etc., and in obstinate forms of 
neuralgia. 

Vesicants are usually applied directly over the affected part, 
though some authorities hold that they should be placed some 
little distance from it. In neuralgia they are often most bene- 
ficial, as Anstie pointed out, when applied to a posterior branch 
of the spinal nerve-trunk from which the painful nerve issues. 
In trifacial neuralgia it is customary to apply the blister be- 
hind the ear. 

The only pustulant in ordinary use is croton oil. 

A mixture of croton oil (see p. 211) and olive oil (1 to 3), 
or the liniment of croton oil of the British Pharmacopoeia 
(croton oil, 1 part ; cajuput oil and rectified spirit, of each, 3 J 
parts), is sometimes of benefit as a counterirritant in bronchitis, 
pleurodynia, and dry pleurisy. 

A large number of drugs which produce irritation when ap- 
plied locally are used for their stimulant effects upon the super- 
ficial tissues themselves in various forms of chronic inflamma- 
tion, such as subcutaneous indurations, indolent ulcers, and 
certain chronic skin diseases. Only those, however, which are 
used almost exclusively for this purpose will be considered 
here: 

Chrysarobin. Chaulmoogra oil. 

Oil of cade. Gurjun balsam. 

Jequirity. 



440 IRRITANTS AND COUNTER IRRITANTS. 

CANTHARIS, U. S. P. 

(Cantharides ; Spanish Flies.) 

Spanish fly is the dried beetle, Cantharis vesicatoria, secured 
chiefly in southern Europe. The active principle is canthari- 
din, the anhydrid of cantharidic acid. The latter does not exist 
uncombined, but its salts are obtained by acting on cantharidin 
with alkalis. Cantharidin occurs in colorless prisms, readily 
soluble in alcohol, ether, chloroform, or oils, but only sparingly 
soluble in water. 

Preparations. Dose. 

Tinctura Cantharidis, U. S. P 1-5 min. (0.06-0.3 c.c.). 

Ceratum Cantharidis, U. S. P. (cantharides, 

32 ; liquid petrolatum, 15 ; yellow wax, 

18 ; rosin, 18, and lard, 17). 
Collodium Cantharidatum, U. S. P. (can- 

tharidal collodion contains 60 per cent. 

of cantharides). 

Physiologic Action. — When applied to the skin, prepara- 
tions of cantharides produce redness and burning, and, later, 
vesication. If the action of the drug be allowed to continue, 
it may ultimately lead to pustulation, ulceration, and sloughing. 
A cerate of good quality requires from six to ten hours to 
produce a blister, the time varying with the part to which it is 
applied and the condition of the skin. To mucous membranes 
cantharides is also highly irritating, that of the genito-urinary 
tract being especially susceptible to its influence. 

Internally doses of from 5-10 min. (0.3-0.6 c.c.) increase to 
some extent the excretion of urine, and often cause frequent 
desire to micturate, with some dysuria. The active principle 
of the drug is rapidly eliminated by the kidneys. Toxic doses 
are followed by intense irritation of the alimentary canal and 
of the genito-urinary tract. The symptoms of poisoning are 
burning pain in the mouth, throat, and stomach, dysphagia, 
great thirst, ptyalism, vomiting and purging of mucous and 
bloody material, and extreme prostration. Later, when a suf- 
ficient quantity of the poison has been absorbed, symptoms 
referable to the genito-urinary tract appear, such as aching 
pains in the loins, a constant desire to urinate, severe vesical 
tenesmus, with the passage of merely a few drops of bloody, 
albuminous urine, and, in males, priapism. Erotic excitement 
sometimes occurs, and in women abortion may follow the 
powerful irritant effects of the drug upon the pelvic viscera. 
In fatal cases death may be preceded by coma and convulsions. 
If the cantharides has been taken in the form of powder, the 



CANTHARIS. 44 1 

characteristic shining green parts of the insect may be recog- 
nized in the vomitus. Section after death shows gastroenteri- 
tis and glomerulonephritis. 

Cantharides is absorbed readily from the skin, and a number 
of cases are on record in which severe and even fatal nephritis 
has resulted from too free vesication. Owing to unusual sus- 
ceptibility, the use even of very small blisters in some persons 
is followed by strangury. 

Treatment of Poisoning". — This consists in evacuating the 
stomach, and in relieving the local irritation by the free admin- 
istration of demulcents. Opium may be required for the pain. 
Fatty substances should be withheld, as they dissolve can- 
tharidin and so favor its absorption. The treatment of can- 
tharidal nephritis does not differ from that usually adopted in 
other forms of the disease. The treatment of strangury con- 
sists in applying hot fomentations to the lower part of the 
abdomen, in giving freely diluent drinks, and in administering 
rectal injections of laudanum. 

Therapeutics. — The most important use of cantharides is 
as a counterirritant. As a vesicant it is often of decided value 
in acute inflammation of serous membranes — pleurisy, pericar- 
ditis, synovitis, etc. In the early stage of these diseases it tends 
to relieve the pain, and, later, it aids in the absorption of the 
effusion. In severe forms of neuritis small blisters may be ap- 
plied with advantage over the course of the affected nerve. 
In facial neuralgia blistering behind the ear may afford 
speedy relief. In acute rheumatism the application of blisters 
around the inflamed joint will often be found to relieve the 
pain and to reduce the swelling. In pneumonia of the usual 
type blisters are of doubtful value, but they are sometimes 
efficacious when used repeatedly in cases of delayed resolution. 
In the early stage of phthisis, when the cough is troublesome, 
counterirritation with cantharides often proves very beneficial. 
In oophoritis the application of a blister over the affected gland 
is very advantageous. Obstinate vomiting due to acute irrita- 
tion of the stomach sometimes yields promptly to a vesicant 
applied to the epigastrium. 

The tincture of cantharides, well diluted, has an established 
reputation as a stimulant lotion in the treatment of premature 
alopecia and alopecia areata. 

R Tincturse cantharidis, fgss (15.0 c.c.) ; 

Tincturse capsici, fgj (30.0 c. c. ) ; 

Olei ricini, fgss (2.0 c.c.) ; 

Alcoholis, q. s. ad f^iv (120.0 c.c). M. 

Sig. Rub into the scalp each night. 



442 IRRITANTS AND COUNTERIRRITANTS. 

Internally cantharides has been used to some extent as a 
stimulant to the genito-urinary tract, in incontinence of urine 
from atony of the bladder, and in chronic pyelitis, cystitis, and 
urethritis, but it is neither so safe nor so efficacious as many 
other remedies in common use. Ringer and others have rec- 
ommended small doses of the tincture in the treatment of acute 
nephritis when all symptoms of active inflammation have sub- 
sided and there is a tendency for the disease to assume a chronic 
type, but we would urge the utmost caution in using the drug 
in such cases. In very large doses, probably by irritating the 
bladder and urethra, cantharides sometimes excites the sexual 
appetite, hence it has been employed as an aphrodisiac; for 
this purpose, however, it is without merit. 

Administration. — The tincture is the only form in which 
the drug is used internally. It should be taken after meals, 
well diluted. For blistering it is customary to use a plaster 
made of the cerate. The market is well supplied with good 
ready-made plasters which may be cut the desired size and 
shape. To obtain the best results the skin should be washed, 
and shaved if necessary, and then thoroughly dried; before 
the plaster is applied it should be moistened with vinegar or a 
few drops of oil. Vesication is generally induced in from six 
to ten hours ; even if it is not, it is advisable to remove the 
plaster at the end of that time and to complete the operation 
by applying a poultice. In delicate subjects the poultice should 
be used at the end of three or four hours. When the bleb has 
fully developed, it should be opened with a large needle, and 
then dressed with a pledget of dry cotton. In many cases 
excellent results are obtained from a succession of blisters ap- 
plied to different parts of the affected region and allowed to 
remain only long enough to produce a rubefacient effect {fly- 
ing blisters). Cantharidal collodion may be used as a blister- 
ing agent in cases in which there is difficulty in controlling the 
patient. 

Contraindications.— Vesicants must be used with the 
greatest caution in very young, old, or debilitated subjects, as 
they may occasion sloughing. For the same reason they 
should be avoided in patients with diabetes. When there 
is active nephritis, some other irritant than cantharides should 
be selected. 

SINAPIS ALBA, U. S. P., AND SINAPIS NIGRA, 

U. S. P. 

(White Mustard and Black Mustard.) 

White mustard is the seed of Smapis alba, and black mus- 
tard is the seed of Brassica nigra. Both of these herbs are 



SINAPIS ALBA — SINAPIS NIGRA. 443 

largely cultivated in Europe and America. The mustard sold 
as a condiment is a mixture of powdered white and black 
mustard, often more or less adulterated. 

White mustard contains a ferment, myrosin, and a glucosid, 
sinalbin. In the presence of water the ferment acts upon the 
glucosid and separates from it an acrid fixed oil — acrinyl sul- 
phocyanate. Black mustard also contains myrosin, and this 
ferment, in the presence of water, acts upon another constitu- 
ent, sinigrin, separating from it an intensely irritant volatile oil 
— ally I isosulphocyanate. 

Preparations. 

Charta Sinapis, U. S. P. (paper spread with a mixture of powdered and 

purified black mustard and an India-rubber solution). 
Oleum Sinapis Volatile, U. S. P. (distilled from a mixture of powdered 

black mustard and water). 

Physiologic Action and Therapeutics. — Mustard made 
into a paste with water and applied to the skin causes redness, 
heat, and burning pain, and, if the contact be prolonged, vesi- 
cation. As the blisters produced by mustard are healed with 
difficulty, the drug is used externally only as a rubefacient 
Applied in the form of a plaster (sinapism) or of the official 
paper, it often affords much relief in various painful affections, 
such as bronchitis, cerebral congestion, headache, intestinal colic y 
gastritis, muscular rheumatism, and neuralgia. A plaster may 
be made by spreading between two layers of thin muslin a 
paste made by mixing ordinary mustard and flour, equal parts, 
with warm water. Hot water should not be used, since high 
temperature destroys the ferment required to evolve the irritant 
oil from the glucosid. Such a plaster should be left on from 
twenty to thirty minutes, or until the skin is quite red. A very 
mild rubefacient effect may be secured by sprinkling a little 
mustard on the surface of a flaxseed poultice. 

Internally, mustard acts as an irritant emetic, evacuating the 
stomach promptly and thoroughly. It may be employed in 
cases of narcotic poisoning, the dose being a tablespoonful 
stirred up in warm water, and repeated, if necessary, in fifteen 
minutes. 

Thiosinamin (Allyl-sulphoured). — This is a compound pro- 
duced by acting on the volatile oil of mustard with ammonia. 
It occurs in colorless, soluble crystals, of bitterish taste and a 
garlicky odor. The reputed action ascribed to it is the soften- 
ing of scar tissue. Hebra, Unna, Juliusberg, Crocker and 
Pernet, and others have recommended it in keloid, post-lupus 



444 IRRITANTS AND COUNTERIRRITANTS. 

scarring, scleroderma, elephantiasis, and cicatricial strictures and 
deformities. It may be given hypodermically every other day, 
in doses of from 1-2 gr. (0.06-0.13 gm.), dissolved in glycerin 
and water, or by the mouth in daily doses of 3 gr. (0.2 gm.). 
Another method of application is by the local use of thiosin- 
amin plasters (10 to 30 per cent). 

Hebra has warned against the use of the drug in all cases 
of partially healed tuberculous foci. 

Fibrolysin. — This is a double salt of thiosinamin and 
sodium salicylate, freely soluble in water. As the solution is 
unstable it is put up in sealed phials, each of which contains 
24 grains (1.5 gm.) of fibrolysin, or the equivalent of 3 grains 
(0.2 gm.) of thiosinamin. 

ARNICA, U. S. P. 

Arnica is official as the flowers of Arnica montana, a peren- 
nial herb growing in the temperate regions of Europe, Asia, 
and America. It contains a volatile oil, tannin, and a gluco- 
sid, arnicin. 

Preparation. Dose. 

Tinctura Arnicae, U. S. P 10-30 min. (0.6-2.0 c.c). 

Physiologic Action and Therapeutics. — Applied to 
the skin, arnica causes redness and burning, and occasionally 
very severe erysipelatous inflammation. Internally, according 
to Hare, moderate doses slow the pulse and raise the blood- 
pressure. Toxic doses cause gastro-intestinal irritation, a 
feeble pulse, profound prostration, and, sometimes, delirium 
and stupor. 

Arnica, in the form of the tincture, has been used very 
largely as a stimulant application in sprains and bruises. In- 
ternally, it has been recommended in a variety of diseases, but 
there is little evidence to show that it is of value in any one of 
them. 

CHRYSAROBINUM, U. S. P. 

(Chrysarobin.) 

Chrysarobin is a neutral principle, more or less impure, ob- 
tained from goa powder, a substance found in the wood of 
Vouacapoua Araroba, a large tree growing in the forests of 
Brazil. It is a yellow, crystalline powder, odorless and taste- 
less, and very slightly soluble in water, alcohol, chloroform, 



OLEUM CADINUM— OLEUM GYNOCARDIA. 445 

or ether. On exposure to air it turns brownish, owing to 
partial oxidation into chrysophanic acid. 

Preparation. 
Unguentum Chrysarobini, U. S. P. (6 per cent.). 

Physiologic Action and Therapeutics. — Chrysarobin 
is a local irritant and a parasiticide. Internally, large doses 
cause gastro-enteritis and nephritis. It is eliminated chiefly by 
the kidneys, partly as chrysophanic acid and partly unchanged. 

Although it stains the skin temporarily and the clothing 
permanently, and, in some persons, causes severe dermatitis, 
chrysarobin is probably the most efficient remedy we have in 
psoriasis. It is adapted to cases in which the patches are com- 
paratively few and large, or to the large patches in extensive 
cases (Stelwagon). If used too freely, it may be absorbed 
and give rise to untoward symptoms. As the conjunctiva is 
exceedingly sensitive to its irritant effect, it should not be em- 
ployed about the face. It may be prescribed in an ointment, 
10-60 gr. (0.65-4.0 gm.) to the ounce (30.0 c.c.) ; suspended 
in chloroform, 1-2 dr. (4.0-8.0 gm.) to the ounce (30.0 c.c.) ; or 
suspended in collodion, 30-60 gr. (2.0-4.0 gm.) to the ounce 
(30.0 c.c). When the infected areas are small, chrysarobin 
may be applied with advantage also in ringworm, either of the 
body or of the scalp. 

OLEUM CADINUM, U. S. P. 

(Oil of Cade ; Juniper Tar Oil.) 

Oil of cade is a volatile oil distilled from the wood of Junip- 
erus Oxycedrus, a shrub resembling the common juniper and 
growing in Southern Europe. It is a thick, dark-brown liquid 
having a tarry odor and taste. It is completely soluble in 
ether or chloroform and partially so in alcohol. 

Therapentics. — The action of oil of cade is very similar to 
that of the oil of tar. The drug is chiefly used as a stimulant 
application in psoriasis and chronic eczema. It may be pre- 
scribed in ointment, 1-3 fl. dr. (4.0-1 1.0 c.c.) to the ounce (30.0 
gm.), or as a pigment made by diluting the oil with one or 
two parts of alcohol. 

OLEUM GYNOCARDIA. 

(Oil of Gynocardia; Chaulmoogra Oil.) 

Chaulmoogra oil is an acrid, whitish fat obtained from the 
seed of Gynocardia odorata, a native of the East Indies. Its 



446 IRRITANTS AND COUNTER IRRITANTS. 

activity is believed to be due to gynocardic acid. It has been 
used with asserted good results, both internally and externally, 
in leprosy. The dose is from 10-30 min. (0.6-2.0 c.c.) in cap- 
sules or in emulsion. Externally, it is prescribed by inunction, 
a 50 per cent, ointment being thoroughly rubbed into the 
affected parts for an hour or two daily. It has been employed 
also to some extent as a local stimulant in sprains and bruises. 

BALSAMUM DIPTEROCARPI. 

(Balsam of Dipterocarpus ; Gurjun Balsam; Wood Oil.) 

Gurjun balsam is an oleoresin obtained by incising Diptero- 
carpus turbinatus and other species of Dipterocarpus , large 
trees growing in India and the East Indies. It contains a 
volatile oil, gurjunic acid, and resin. It has been used largely 
to adulterate the oleoresin of copaiba, which it resembles very 
closely in its properties. It is said to be of value, both as an 
internal remedy and as a local application in leprosy. The 
dose is from 10-40 min. (0.6-2.5 c.c), in emulsion. Externally 
it is applied by inunction, diluted with from I to 3 parts of lime- 
water or olive oil. 

OTHER COUNTERIRRITANTS. 

Oil of Turpentine (see p. 236). — In the form of a stupe, 
oil of turpentine makes an excellent rubefacient application in 
a large number of affections attended with pain or irritation, 
such as muscular rheumatism, intestinal colic, gastralgia, bron- 
chitis, and pulmonary congestion. Turpentine liniment applied 
with friction is useful in muscular rheumatism, chronic articular 
rheumatism, and chilblain. 

Iodin (see p. 317). — As a counterirritant, iodin is well 
adapted to conditions requiring a mild but persistent effect 
The tincture applied as a pigment is extensively employed in 
such affections as laryngitis, pleurisy, synovitis, arthritis, neu- 
ritis, periostitis , bubo, and chilblain. 

Capsicum (see p. 185). — Tincture of capsicum, more or less 
diluted, may be applied as a lotion in acute torticollis and chil- 
blain. Capsicum plaster is sometimes serviceable in relieving 
lumbago and other muscular pains. 

Chloroform (see p. 123), Aconite (see p. 60), Ammonia 
(see p. 41), Camphor (see p. 132). — These drugs are exten- 
sively employed as rubefacients in the form of liniments. 
They are often combined with advantage, as in the following 
formula : 



ESCHAROTICS OR CAUSTICS. 447 

R Tincturse aconiti, 
Chloroformi, 

Olei terebinthinae, aa f.^ss; 

Linimenti saponis, f ^iij. M. 

JEQUIRITY. 

(Abrus ; Prayer Beads.) 

Jequirity is the seed of Abrus precatorius, a plant growing 
in India and in Brazil. It contains a toxalbumin known as 
abnn. In the form of a freshly prepared infusion (3 per 
cent.) it has been used as a local remedy in the treatment of 
chronic granular conjunctivitis and of the corneal pannus asso- 
ciated with this disease. Applied to the eye, it produces a 
severe membranous conjunctivitis which must be controlled 
by cold compresses. As the treatment is somewhat hazardous, 
it is rarely employed at the present day except in long-stand- 
ing cases of trachoma with very dense pannus. 



ESCHAROTICS OR CAUSTICS. 

Escharotics or caustics are agents that corrode or dis- 
organize the tissues. Some, like arsensic, have a specific 
poisonous action upon the cells ; some, like the strong mineral 
acids, extract water from the tissues and precipitate the pro- 
teids ; some, like the alkaline hydrates, not only extract water, 
but dissolve the proteids and form with them soluble com- 
pounds ; some, like the nitrate of lead, form with the proteids 
insoluble albuminates, and in so doing also liberate an acid ; 
some, like the nitrate of mercury, poison the cells directly, 
form albuminates with the proteids, and also set free an acid ; 
while others still, like bromin, are powerful oxidizers of or- 
ganic matter. The most important escharotics are : 

Sulphuric acid. Osmic acid. 

Nitric acid. Bromin. 

Carbolic acid. Potassium hydroxid. 

Arsenic trioxid. Sodium hydroxid. 

Acetic acid. Sodium ethylate. 

Trichloracetic acid. Zinc chlorid. 
Chromium trioxid (chromic acid). Mercuric nitrate. 

Lactic acid. Silver nitrate. 

Pyrogallic acid. Lead nitrate. 

The actual cautery (hot iron ; Paquelin cautery ; galvano- 



448 ESCHAR TICS OR CAUSTICS. 

cautery) also offers a prompt and powerful means of destroying 
tissue. 

Escharotics are used to destroy exuberant granulations, the 
tissue around poisoned wounds, and small growths, such as 
warts, epitheliomata, and lupus infiltrations, and also to modify 
the specific character of phagedenic ulcers and sloughing 
wounds. 

Depilatories are agents employed to remove superfluous 
hair. The most important are barium sulphid and calcium 
sulphydrate. Permanent removal of hair can be effected only 
by electrolysis. 

ACIDUM SULPHURICUM, U. S. P. 

(Sulphuric Acid ; Oil of Vitriol ; H 2 S0 4 .) 

Official sulphuric acid is a colorless, heavy, oily liquid, odor- 
less, and of intensely sour taste and acid reaction. It has a 
marked affinity for water, with which it mixes with the evolu- 
tion of heat. It rapidly chars and destroys organic matter. 

Preparations. Dose. 

Acidum Sulphuricum Dilutum, U. S. P. 
(contains 10 per cent, of absolute sul- 
phuric acid) 10-20 min. (0.6-1.2 c.c). 

Acidum Sulphuricum Aromaticum, U. S. P. 
(an alcoholic solution containing about 
20 per cent, of the official acid, with ginger 
and cinnamon) 5-20 min. (0.3-1.2 c.c). 

Physiologic Action. — When applied to the skin in con- 
centrated form, sulphuric acid causes intense pain and a rapid 
destruction of tissue, the eschar being first white and then 
brown or black. Upon mucous membranes it has a still more 
irritant and corrosive effect. The local corrosion results from 
the extraction of water, the neutralization of the alkalis, and 
the precipitation of albumins. Internally, large doses produce 
burning in the throat and gullet, violent pain in the abdomen, 
constant vomiting of dark matter, often mixed with blood and 
mucus, intense thirst, difficult breathing, and collapse. Death 
usually occurs within twenty-four hours, and if the acid has 
reached the larynx, a fatal termination may result almost im- 
mediately from suffocation. Blackish stains on the clothing 
may serve as a clue to the recognition of the poison. 

Even in very dilute form sulphuric and other mineral acids, 
in large doses, may prove fatal to herbivorous animals by over- 
coming the alkalinity of the blood, thereby rendering it in- 
capable of removing carbonic acid from the tissues. Such an 
untoward effect, however, can scarcely occur in carnivorous 



ACIDUM NITRICUM. 449 

animals or in man, since in them the tissues under the influence 
of the acid yield large quantities of ammonia, which unites 
with acid, thus protecting the alkalis of the blood from neutral- 
ization. Sulphuric acid circulates in the blood in the form of 
its salts, and is rapidly eliminated in the urine chiefly as acid 
salts. 

Treatment of Poisoning". — This consists in administering 
alkalis, — chalk, magnesia, soap, white-wash, or alkaline car- 
bonates, — together with demulcent drinks, such as albumin- 
water, milk, or barley-water. Opium is always required to 
relieve the severe pain. The stomach-pump should be avoided 
on account of the risk of piercing the softened esophagus. 

Therapeutics. — Sulphuric acid, owing to the severity of 
its action, is less useful as an escharotic than some of the 
other acids. It is occasionally employed, however, as a caustic 
in phagedenic chancroid, being applied in the form of a paste 
made by mixing the acid with some indifferent substance, such 
as charcoal or asbestos. It has been used also to a limited 
extent in caries, to hasten the removal of the diseased bone. 

Internally, in the form of aromatic sulphuric acid, it is some- 
times of service as an antihydrotic in the night-sweats of 
phthisis. Combined with opium, it has been recommended in 
serons diarrhea. Sulphuric acid lemonade has been used by 
workers in lead as a prophylactic against plnmbism. 

Administration. — Sulphuric acid should be given well 
diluted, precautions being taken to prevent its action on the 
teeth. 

Incompatibles. — Alkalis, alkaline carbonates, iodids, and 
salts of lead and of lime. It is explosive with sugar and oil 
of turpentine. The undiluted acid carbonizes syrups. 

ACIDUM NITRICUM, U. S. P. 

(Nitric Acid; HN0 3 .) 

The official nitric acid is a colorless, intensely acid, fuming 
liquid composed of 68 per cent, of absolute nitric acid and 32 
per cent, of water. 

Preparations. Dose. 

Acidum Nitricum Dilutum. U. S. P. (10 
per cent, by weight of absolute nitric 
acid) 5-20 min. (0.3-1.2 c.c). 

Acidum Nitrohydrochloricum, U. S. P. 
(aqua regia : nitric acid, 18; hydro- 
chloric acid, 82) 2-4 min. (0.1-0.25 c.c). 

Acidum Nitrohydrochloricum Dilutum, 
U. S. P. (nitric acid, 4 ; hydrochloric acid, 
18; water, 78) . - 5-20 min. (0.3-1.2 c.c). 



450 ESCHAROTICS OR CAUSTICS. 

Physiologic Action and Therapeutics. — Locally, pure 
nitric acid is a powerful caustic, but somewhat less painful and 
less penetrant than sulphuric acid. It stains the skin yellow. 
In overdoses it produces symptoms and lesions (except the yel- 
low coloration) similar to those produced by sulphuric acid, 
and in poisoning the same treatment is applicable. 

As an escharotic, nitric acid is generally preferred to other 
mineral acids, as its action is more readily controlled. It has 
been found reliable in phagedenic ulcers, chancroids, and 
chancres, and in hospital gangrene. It has been used very suc- 
cessfully also, when milder measures have failed, as a means of 
producing inflammatory contractile tissue in prolapse of the 
rectum occurring in children. 

Internally, dilute nitric acid has been recommended by 
Ringer and others in indigestion, especially when eructation of 
offensive gas is a prominent symptom, or when there is a ten- 
dency to persistent aphthous stomatitis. It should be taken 
well diluted through a glass tube. 

Incompatibles. — Alkalis, carbonates, oxids, lead acetate, 
and iron sulphate. The strong acid forms explosive compounds 
with readily oxidizable substances, such as glycerin, alcohol, 
phenol, resins, volatile oils, etc. 

Nitrohydrochloric Acid. — This is a yellow, fuming, cor- 
rosive liquid produced by mixing nitric acid with hydrochloric 
acid. Both acids undergo decomposition with the formation of 
nitrosyl chlorid (NOC1) and chlorin. Nitrohydrochloric acid 
is believed to have a special action on the liver ; whether this 
be true or not, the drug is often of value in that form of 
indigestion which culminates at frequent intervals in so-called 
bilious attacks. It has a well-deserved reputation also in mal- 
assimilation manifested by gaseous eructations, great mental 
depression, and persistent oxaluria. The best results are ob- 
tained by using the strong acid, freshly prepared, though 
considerable care must be exercised in handling it. It should 
be taken after meals, well diluted, through a tube. It should 
not be prescribed undiluted with tinctures or other alcoholic 
preparations, as such mixtures are liable to explode. 

Nitrohydrochloric-acid baths were formerly employed rather 
extensively in various affections of the liver, but it is doubtful 
whether they exerted any influence beyond a beneficial stimula- 
tion of the skin. Nitrohydrochloric acid is not used as an 
escharotic. 



ACIDUM ACETICUM—CHROMII TRIOXIDUM. 45 I 

ACIDUM ACETICUM. 

(Acetic Acid; HC 2 H,0 2 .) 

Acetic acid is official in the following forms : 

Acidum Aceticum, U. S. P. (36 per cent, by weight of absolute acetic 

acid). 
Acidum Aceticum Dilutum, U. S. P. (6 per cent, by weight of absolute 

acetic acid). 
Acidum Aceticum Glaciale, U. S. P. (nearly absolute acetic acid). 

Vinegar (acetum) is not official, but has the same therapeutic 
value as diluted acetic acid. 

Physiologic Action and Therapeutics. — Locally ap- 
plied, concentrated acetic acid produces redness, vesication, and 
ultimately superficial sloughing. Taken internally, it causes 
severe gastritis. Even small doses of acetic acid, if long con- 
tinued, cause chronic gastric catarrh. It is eliminated as car- 
bonates, so it does not increase the acidity of the urine. 

Glacial acetic acid is sometimes employed to remove warts 
and corns. Inhalations of diluted acetic acid or of vinegar are 
often useful in checking vomiting occurring after general anes- 
thesia. Vinegar is of service as a local hemostatic in epistaxis, 
leech-bites, and small wounds, as well as in postpartum hemor- 
rhage. In the form of an enema it is occasionally employed to 
destroy oxyures. Internally, it may be used as an antidote in 
poisoning by alkalis. 

ACIDUM TRICHLORACETICUM, U. S. P. 

(Trichloracetic Acid; HC 2 C1 3 2 .) 

Trichloracetic acid is formed by acting on glacial acetic acid 
with chlorin or on hydrated chloral with fuming nitric acid. 
It occurs in colorless, hygroscopic crystals, of pungent odor 
and strong acid reaction. 

Therapeutics. — Pure or in concentrated solution, trichlor- 
acetic acid has been used to some extent as a caustic for remov- 
ing small growths, such as venereal or cutaneous warts, nevi, and 
corns. A solution of from 5 to 10 per cent, makes an excel- 
lent stimulant application in chancroids, mucous patches, tuber- 
culous ulcers, and fistidous tracts. In this strength it causes 
but little pain or inflammatory reaction. 

CHROMII TRIOXIDUM, U. S. P. 

(Chromium Trioxid ; Chromic Acid; Chromic Anhydrid ; Cr0 3 .) 

Chromium trioxid, or so-called chromic acid, occurs in crim- 
son, deliquescent crystals, odorless, and readily soluble in 



452 ESCHAR OTICS OR CAUSTICS. 

water. With organic matter, alcohol, glycerin, ether, tannin, 
sugar, etc., it is explosive. 
Physiologic Action and Therapeutics.— Owing to its 

strong oxidizing power chromic acid is an energetic caustic, 
slower and somewhat less painful in its action, however, than 
nitric acid, potassa, or silver nitrate. Internally, it is an active 
poison, producing severe abdominal pain, vomiting, purging, 
albuminuria, and collapse. The vomited matters are often of 
a green or bluish-green color. The postmortem lesions con- 
sist in inflammation and erosion of the gastro-intestinal mu- 
cous membrane, nephritis, and fatty degeneration of the tissues, 
especially of the liver. Alkalis neutralize the acid, but as they 
form poisonous salts, the stomach should be thoroughly 
emptied after their administration. The local application or in- 
halation of chromium compounds may also result in poisoning. 
Workers in these preparations not infrequently suffer from ul- 
cerations of the skin and mucous membranes, chronic bron- 
chitis, and interstitial nephritis. 

Chromic acid may be used to destroy small growths, like 
common warts, venereal warts, and corns. For this purpose it 
may be applied in substance or in strong solution — 2-3 dr. (8.0- 
12.0 gm.) to the ounce (30.0 c.c). The fused acid on a probe 
may also be employed successfully in removing soft hyper- 
trophies of the nasopharyngeal mucous membrane and in clos- 
ing small salivary fistulce. A solution of from 20-30 gr. (1.3— 
2.0 gm.) to the ounce (30.0 c.c.) makes an excellent stimulant 
application in mucous patches. A solution of 40 gr. (2.6 gm.) to 
the ounce (30.0 c.c), applied once a week, has been well rec- 
ommended in hyperidrosis and bromidrosis of the feet. 

Potassium Bichromate. — This salt, in doses of from 
j 1 ^ ^ gr. (0.005-0.0065 gm.), has been used with good results 
by Frazer, Bradbury, White, and others in chronic gastric 
catarrh and gastric ulcer. It should be given in capsules or in 
pills made with kaolin, thrice daily, on an empty stomach. 

ACIDUM LACTICUM, U. S. P. 

(Lactic Acid; HC 3 H 5 3 .) 

Lactic acid is an organic acid usually obtained by subjecting 
milk-sugar or grape-sugar to lactic fermentation. The official 
preparation is composed of 75 per cent, by weight of absolute 
lactic acid and 25 per cent, of water. 

Therapeutics. — Lactic acid, in solutions of from 20 to 100 
per cent, is a valuable application in tuberculous and hipous 
ulcerations of mucous membranes. In the proportion of 1 part 



■ PYROGALLOL—ACIDUM OSMICUM. 453 

of the acid to from 5-20 parts of water it sometimes proves 
efficacious in freckles and chloasma. 

PYROGALLOL, U. S. P. 

(Pyrogallic Acid; C 6 H 3 (OH 3 ).) 

Pyrogallic acid is produced by the action of heat on gallic 
acid. It occurs in white, lustrous needles or scales, odorless, 
and of a bitter taste. It is readily soluble in water, alcohol, 
or ether. 

Physiologic Action and Therapeutics. — Locally, pyro- 
gallol is an irritant or caustic, according as it is applied in 
dilute or in concentrated form. It is also an active parasiticide. 
It stains the skin a brownish color. As a caustic its action is 
slow and attended with but little pain. Owing to its power to 
destroy the red blood-cells and to convert hemoglobin into 
methemoglobin/ grave, or even fatal, toxic effects may result 
from the application of the drug over too large a surface. 

Pyrogallol is an efficient caustic in lupus and epithelioma, 
when the lesions are small. It is generally applied in the form 
of an ointment, from 20-40 per cent, in strength. Stelwagon 
recommends the following formula : 

R Pyrogallol, ^ij-iij (8.0-12.0 gm.) ; 

Cerati resinse, 
Petrolati, aa q. s. ad 3jj (31.0 gm.). M. 

Such an ointment should be applied on lint, and renewed 
twice a day for two or three weeks, the superficial sloughs 
being removed every few days by poulticing or gentle scrap- 
ing. 

An ointment containing from 20-60 gr. (1.3-4.0 gm.) of 
pyrogallol to the ounce (31.0 gm.) is sometimes useful in 
psoriasis. 

ACIDUM OSMICUM. 

(Osmic Acid; Osmium Tetroxid; Os0 4 .) 

Osmic acid occurs in yellow, crystalline needles, having a 
pungent odor and a burning taste. It is readily soluble in 
water, alcohol, or ether. 

Therapeutics. — Even in weak solution, it is exceedingly 
irritant and caustic. Stekoulis, Schapiro, Bennett, and others 
claim excellent results from injections of osmic acid in neural- 
gia. The nerve having been exposed by a small incision, a 
1.5 per cent, solution, freshly prepared, is injected into it at 
several points, to the amount of from 5-10 min. (0.3-0.6 c.c). 
The blood and tissues are stained intensely black by the acid, 



454 ESCHAROTICS OR CAUSTICS. 

but healing of the wound is said to proceed rapidly without 
suppuration. 

BROMUM, U. S. P. 

(Bromin; Br.) 

Bromin is a non-metallic element obtained from sea-water. 
It is a dark, reddish-brown liquid, evolving, even at ordinary 
temperatures, suffocating and irritating fumes. It is soluble in 
28 parts of water and readily soluble in alcohol or ether. 

Physiologic Action and Therapeutics. — Bromin is an 
intensely active and painful escharotic. It is also a disinfectant 
and deodorant. When ingested, it causes inflammation and 
extensive necrosis of the gastro-intestinal mucosa. Inhaled, it 
acts like chlorin, producing mucopurulent bronchitis, edema of 
the lungs, and foci of catarrhal pneumonia. 

Bromin has been used as an escharotic in phagedenic and 
cancerous ulcerations, but, owing to the difficulty in handling it 
and the great pain caused by its application, it is rarely em- 
ployed at the present time. It is still occasionally used in very 
weak solutions as a deodoi'ant (see p. 414). 

Bromipin. — This preparation is an addition-product of 
sesame oil and bromin (10 per cent.). It is a yellowish, oily 
liquid, free from the caustic properties of bromin. In daily 
doses of from 1-3 fl. dr. (4.0-1 1.0 c.c.) it has been used with 
asserted good results as a substitute for the bromids in epilepsy. 

POTASSII HYDROXIDUM, U. S. P. 

(Potassium Hydroxid ; Caustic Potash; KOH.) 

Caustic potash occurs in hard white pencils or fused masses, 
odorless, deliquescent, strongly alkaline, and corrosive. It is 
soluble in 0.4 part of water and in 2 parts of alcohol. 

Preparation. Dose. 

Liquor Potassii Hydroxidi, U. S. P. (5 per cent.) . . 5-30 min. (0.3-2.0 c.c). 

Physiologic Action and Therapeutics. — In concen- 
trated form, potassium hydroxid is a diffusive and deeply pene- 
trating escharotic. Its action is rapid and painful. It produces 
a grayish, soft, and pultaceous slough, which separates in a few 
days, leaving an ulcer. Its caustic properties are due to the 
power of its hydroxyl molecule to abstract water from the 
tissues, to soften and dissolve them, and to form with the pro- 



SOD II HYDROXIDUM. 455 

teids a soluble alkaline albuminate. When swallowed in 
strong solution it produces all the symptoms of a violent cor- 
rosive poison — burning in the throat and gullet, intense ab- 
dominal pain, vomiting and purging of mucous and bloody 
matter, dysphagia, hoarseness, and collapse. If recovery fol- 
lows, stricture of the esophagus or cicatricial contractions of 
the stomach may result from the extensive ulceration. 

Small doses, in dilute solution, exert an influence similar to 
that of the alkaline carbonates (see Gastric Antacids). The 
drug is eliminated as a carbonate, chiefly in the urine. 

Treatment of Poisoning'. — This consists in neutralizing 
the alkali with a weak acid, such as vinegar or lemon-juice, 
and in allaying the irritation and pain with demulcents and 
opium. 

As an escharotic, caustic potash may be used to remove 
common warts and small cutaneous cancers. For this purpose 
the solid stick should be used, the surrounding parts being 
protected by a coating of oil. When the desired effect has 
been attained, further action may be prevented by the applica- 
tion of vinegar. Caustic potash is also an efficient agent with 
which to cauterize the bites of rabid animals. In ingrowing 
toe-nail, the insertion under the nail of a pledget of cotton 
soaked in liquor potassii hydroxidi (1 part to 4 parts of water) 
affords an excellent means of removing the redundant tissue, 
thus facilitating the raising of the nail. The diffusive action 
of potassium hydroxid renders it unsuitable for use on mucous 
membranes. 

A mixture of equal parts of potassium hydroxid and lime 
( Vienna paste) being less deliquescent than pure caustic potash, 
is more manageable than the latter, but slower in its action. 

Internally, solution of potassium hydroxid, well diluted, is 
rarely used as an antacid. 

Incompatibles. — Acids, acid salts, metallic salts, and 
alkaloids. 

SODII HYDROXIDUM, U. S. P. 

(Sodium Hydroxid ; Caustic Soda ; NaOH.) 

Caustic soda occurs in white, translucent pencils or fused 
masses, odorless, of an acrid, caustic taste and an intensely 
alkaline reaction. It is readily soluble in water and in alcohoL 

Preparation. Dose. 

Liquor Sodii Hydroxidi, U. S. P 5-30 min. (0.3-2.0 cc). 

Therapeutics. — Caustic soda may be used for the same 
purposes as caustic potash, the action of the two drugs being 
similar. 



456 ESCHAROTICS OR CAUSTICS. 

SODII ETHYLAS. 

(Sodium Ethylate; Sodium Alcohol; NaC 2 H 5 0.) 

A solution of sodium ethylate, made by dissolving I part of 
metallic sodium in 20 parts of absolute alcohol, has been used, 
on the recommendation of B. W. Richardson, as a caustic to 
remove vascular nevi and warts. It should be applied with 
a glass rod, and the superficial dry crust formed allowed to 
come off spontaneously. It is said to cause less scarring than 
other caustics. It is decomposed by water. 

BARII SULPHIDUM. 

(Barium Sulphid; BaS.) 

Barium sulphid is an amorphous, pale yellow, phosphores- 
cent powder, soluble in water. Diluted with from I to 3 parts 
of some inert powder, it is used as a depilatory. Duhring 
recommends : 

R Barii sulphidi, 5jj-ij (4.0-8.0 gm.) ; 

Amyli, 
Zinci oxidi, aa giss (6.0 gm.). M. 

At the time of application sufficient water is added to make 
a paste, which is thickly spread over the affected part and 
allowed to remain for a minute or two or until it excites slight 
burning. 

Barium sulphid deteriorates with age and on exposure to 
air. 

CALCII SULPHIDUM HYDRATUM. 

(Hydrated Calcium Sulphid; Calcium Sulphohydrate ; CaS -\- H 2 0.) 

Hydrated calcium sulphid is a whitish or pale-pink powder, 
made by heating together at a high temperature calcium sul- 
phate and granulated wood-charcoal. In the form of a paste 
it has been recommended by Kaposi, Brayton, and others as a 
harmless depilatory. When wetted, it gives off hydrogen sul- 
phid, which is sometimes a drawback to its use. 



OTHER ESCHAROTICS. 

Arsenic Trioxid (see p. 305). — Arsenic is a slowly acting 
but deeply penetrating escharotic. It causes severe pain and 
considerable inflammatory swelling, and, if applied over too large 
a surface, may prove dangerous through absorption. On the 
other hand, its action, while very thorough, is largely limited to 



OTHER ESCHAR OTICS. 



457 



the diseased tissue. Its modus operandi is not definitely known, 
but as it does not combine chemically with the tissues, it is 
supposed to act directly upon the cells in a specifically poison- 
ous manner. The employment of arsenic as an escharotic is 
practically confined to the removal of small cutaneous cancers 
and lupus infiltrations (see p. 309) and the destruction of the 
pidp in carious teeth. 

Carbolic Acid (see p, 387). — Carbolic acid is a compara- 
tively superficial escharotic, the deeper tissues being protected 
by an albuminous coagulum. Owing to the property which it 
possesses of paralyzing the peripheral sensory nerves, its appli- 
cation is not followed by very severe or persistent pain. Abso- 
lute alcohol, as Phelps and Powell have shown, destroys its 
caustic action. After thorough curetment of the parts pure 
liquid carbolic acid may be applied with advantage in inflamma- 
tory gangrene, irritable tilcers, carbuncles, and ftstulce. Local in- 
jections of the pure acid are also efficacious in anthrax (see p. 
389). Von Bruns claims excellent results in the treatment of 
infected wounds from the application of pure carbolic acid in 
small quantities and for one minute, followed immediately by 
irrigation with absolute alcohol. 

Mercuric Nitrate (see p. 332). — This salt is an exceed- 
ingly irritant and powerful escharotic. Its action depends upon 
several factors : (1) The union of the metal with the proteids to 
form a soluble albuminate ; (2) the liberation of nitric acid, 
which is also caustic ; and (3) the toxic effects upon the cells 
of the mercury itself. As an escharotic it has been exten- 
sively employed in the form of the solution of mercuric nitrate 
in phagedenic venereal sores. If used too freely, it is liable to 
be absorbed and to induce salivation. 

^inc Chlorid (see p. 369). — This salt is an energetic and 
very painful caustic. It produces a dry, whitish slough, the 
separation of which usually requires from one to three weeks. 
Unlike arsenic, it does not spare the healthy tissue. In the 
form of a paste to which cocain has been added, it is some- 
times used to remove cutaneous epitheliomata. 

Silver Nitrate (see p. 370). — The insoluble and impene- 
trable pellicle of silver albuminate which lunar caustic immedi- 
ately forms when brought in contact with the tissues confines 
its destructive action to the superficial cells. In the form of 
the solid stick it is an excellent caustic for removing such for- 
mations as small warts, mucous patches, and exuberant granu- 
latio?is. 

I^ead nitrate (see p. 365). — The corrosive action of this 
salt of lead is due largely to the nitric acid which is liberated 



458 PRO TECTIVES. 

when it is brought in contact with proteid matter. It is some- 
times used in the form of a powder as a caustic in onychia. 



PROTECTIVES. 

Protectives are agents that serve to protect inflamed or injured 
surfaces from external irritation. Their action is chiefly 
mechanical. Those of a mucoid or colloid nature, which exert 
a soothing effect upon inflamed parts, are known as demul- 
cents. The most important members of this subdivision are : 

Flaxseed. Marshmallow. 

Acacia. Licorice root. 

Tragacanth. Almond. 

Sassafras pith. Starch. 

Slippery elm. White and yolk of egg. 

Internally, demulcents are especially useful in protecting the 
walls of the stomach from the action of corrosive poisons. 
Made up into lozenges and allowed to dissolve slowly in the 
mouth they tend to subdue pain and cough resulting from 
irritation of the throat. In the form of enemata, they are used 
to relieve the tenesmus of acute dysentery. Externally they 
are rarely employed except in the form of poultices, and even 
in this form they are used more as a means of applying heat 
and moisture than as protectives. Hot poultices are very effi- 
cacious in relaxing local spasms, such as occur in asthma and 
the various forms of colic. In deep-seated inflammations — 
pneumonia, nephritis, cystitis, etc. — they usually afford con- 
siderable comfort, and no doubt exert a reflex influence on the 
morbid process itself (see Counterirritants). In superficial in- 
flammations hot antiseptic fomentations have largely supplanted 
ordinary poultices, because the latter afford such excellent 
media for the growth of bacteria. When suppuration has 
already occurred or is obviously inevitable, poultices are wholly 
inadmissible. 

Protectives of a fatty character, intended to shield the skin 
from external irritants and at the same time to soften and relax 
it, are known as emollients. The most important are : 



Lard. 


Almond oil. 


Suet. 


Linseed oil. 


Wool-fat. 


Petrolatum. 


Spermaceti. 


Glycerin. 


Olive oil. 


Wax. 



linum. 459 

Emollients are used for their protective and soothing prop- 
erties in burns, in Assuring of the lips and hands, and in acute 
inflammatory diseases of the skin. They are also extensively 
employed as bases for special ointments. 

The so-called dusting-powders constitute another group 
of protectives. The requisites of a good dusting-powder are 
dryness, insolubility, inertness, and absolute freedom from 
grittiness. Those in common use are : 

Starch. Zinc oxid. 

Talc. Chalk. 

Kaolin. Magnesium carbonate. 

Lycopodium. 

Dusting-powders are prescribed in various forms of erythema 
and in acute eczema to protect the parts from air, moisture, and 
friction. 

Finally, certain protectives which have strong adhesive prop- 
erties and can be kept in place for several days without change 
are employed as fixed dressings. In this class are : 

Collodion. Solution of gutta-percha. 

Lead plaster (Emplastrum Plumbi, U. S. P.), adhesive or 
rubber (Emplastrum Adhcesivum, U. S. P.), and soap plaster 
(Emplastrum Saponis, U. S. P.) also belong in this group. 

Fixed dressings are frequently of service in the treatment 
of abrasions, small wounds, fissures, and bed-sores. 

LINUM, U. S. P. 

(Linseed; Flaxseed.) 

Linseed is the seed of Linum usitatissimum, or common 
flax, an annual cultivated in all temperate countries. From a 
therapeutic standpoint its chief ingredients are a mucilaginous 
principle and a fixed oil. 

Preparations. 

Oleum Lini, U. S. P. 

Linimentum Calcis, U. S. P. (Carron-oil : equal parts of linseed oil and lime- 
water). 

Sapo Mollis, U. S. P. (soft or green soap). 

Linimentum Saponis Mollis, U. S. P. (tincture of green soap : soft soap, 
65 ; oil of lavender, 2; alcohol to make 100). 

Liquor Cresolis Compositus, U. S. P. 



460 PROTECTIVES. 

Therapeutics. — An infusion or tea of flaxseed serves as 
an excellent demulcent drink. Ground flaxseed is the material 
most commonly selected for making ordinary poultices. Soft 
soap and liniment of soft soap are used for detergent purposes 
and also for removing crusts and scales in sluggish diseases of 
the skin like seborrhea and psoriasis. 

ACACIA, U. S. P. 

(Gum Arabic.) 

Acacia is a gummy exudation obtained from Acacia Senegal \ 
a small tree growing in Senegal, Kordofan, and Abyssinia. It 
contains arable acid in combination with calcium, magnesium, 
and potassium. 

Preparations. Dose. 

Mucilago Acaciae, U. S. P Indefinite. 

Syrupus Acaciae, U. S. P Indefinite. 

Pulvis Cretse Compositus, U. S. P 5~6o gr. (0.3-4.0 gm.). 

Acacia also enters into chalk mixture, compound mixture 
of glycyrrhiza, emulsion of almond, emulsion of cod-liver oil, 
emulsion of cod-liver oil with hypophosphites, emulsion of oil 
of turpentine, and several troches and pills. 

Therapeutics. — In therapeutics acacia is used chiefly as a 
demulcent ; in pharmacy it is used for holding together the 
active ingredients in pills and lozenges and for suspending 
insoluble substances in water. It is precipitated from its solu- 
tion by alcohol, subacetate of lead, ferric salts, and borax. 

TRAGACANTHA, U. S. P. 

(Tragacanth.) 

Tragacanth is a gummy exudation from Astragalus gum- 
mifer, a shrub growing in western Asia. It contains tragan- 
thin or bassorin and the calcium salt of gummic acid. It swells 
up in water into a gelatinous mass, but, unlike acacia, does not 
dissolve in it. 

Preparation. 
Mucilago Tragacanthse, U. S. P. 

Tragacanth also enters into emulsion of chloroform and 
most of the official troches. 

Therapeutics. — On account of its insolubility, it is rarely 
used as a demulcent. It is employed in pharmacy for sus- 
pending resins, oils, and heavy powders in water. 



SASSAFRAS MEDULLA— GLYCYRRHIZA 461 

SASSAFRAS MEDULLA, U. S. P. 

(Sassafras Pith.) 

Sassafras pith is obtained from the branches of Sassafras 
variifolium, a tree growing in the woods of North America. 

Preparation. 
Mucilago Sassafras Medullae, U. S. P. 

Therapeutics. — The mucilage has demulcent properties, 
but it is rarely used except in domestic medicine. 

ULMUS, U. S. P. 

(Slippery Elm. ) 

Slippery elm is the inner bark of Ulmus fulva, a large tree 
growing in the Eastern States of North America. It contains 
a large quantity of mucilaginous matter. 

Preparation. 
Mucilago Ulmi, U. S. P. 

Therapeutics. — The powdered bark is sometimes used 
instead of flaxseed meal for making small poultices. In the 
form of lozenges it is sometimes employed for its soothing 
properties in pharyngitis. 

ALTH^A, U. S. P. 

(Marshmallow. ) 

Marshmallow is the root of Althcea officinalis, a perennial 
herb growing in most temperate countries. It contains a large 
amount of mucilage and of starch. It is an ingredient of 
blue-mass, pills of phosphorus, and pills of carbonate of 
iron. 

Therapeutics. — Although it is an agreeable demulcent, 
marshmallow is rarely prescribed at the present time. 



GLYCYRRHIZA, U. S. P. 

(Licorice Root.) 

Glycyrrhiza is the root of Glycyrrhiza glabra, or Glycyrrhiza 
glandulifera, a perennial herb growing in southern Europe 
and western Asia and cultivated in England and the United 



462 PROTECTIVES. 

States. It contains a glucosid, glycyrrhizin, to which it owes 
its sweet taste. 

Preparations. Dose. 

Extractum Glycyrrhizae, U. S. P Indefinite. 

Extractum Glycyrrhizae Purum, U. S. P. . . Indefinite, 
Glycyrrhizinum Ammoniatum, U. S. P. . . 5— 15 gr. (0.3-I.0 gm.). 
Fluidextractum Glycyrrhizae, U. S. P. . . . \-2 fl. dr. (2.0-8.0 c.c). 
Mistura Glycyrrhizae Composita, U. S. P. 

(brown mixture : Pure extract of licorice, 

3; syrup, 5; acacia, 3; paregoric, 12; 

wine of antimony, 6; spirit of nitrous 

ether, 3; water to make 100) 1-4 fl. dr. (4.0-15.0 c.c). 

Pulvis Glycyrrhizae Compositus, U. S. P. 

(glycyrrhiza, 23.6; senna, 18; washed 

sulphur, 8 ; fennel oil, 0.4; sugar, 50) . . \-2 dr. (2.0-8.0 gm.). 
Trochisci Glycyrrhizae et Opii, U. S. P. 

(each contains extract of glycyrrhiza, 2\ 

gr. — 0.15 gm. — and powdered opium, T x ? 

gr.— 0.005 gm.). 

Glycyrrhiza also enters into aromatic fluid extract of cascara 
sagrada, compound fluid extract of sarsaparilla, compound 
syrup of sarsaparilla, tincture of aloes, tincture of aloes and 
myrrh, mass of mercury, pills of ferrous iodid, compound 
laxative pills, troches of ammonium chlorid, and troches of 
cubeb. 

Therapeutics. — Licorice is a popular remedy for cough 
resulting from irritation of upper respiratory tract. It is also 
largely employed to cover the disagreeable taste of other medi- 
cines. 

AMYGDALA. 

(Almond.) 

Almonds are official in two forms : bitter almonds {Amyg- 
dala Amara, U. S. P.) and sweet almonds {Amygdala Dulcis, 
U. S. P.). Both varieties contain a fixed oil and a ferment, 
emulsin. Bitter almonds contain also a glucosid, amygdalin y 
which, in the presence of water, is acted upon by the emul- 
sin and broken up into hydrocyanic acid, benzaldehyd, and 
glucose. Oil of bitter almond {Oleum Amygdala Amara, 
U. S. P.) is a loose combination of hydrocyanic acid (2.0-4.0 
per cent.) and benzaldehyd (85 per cent.), obtained by dis- 
tillation. As sweet almonds do not contain amygdalin, 
they do not yield hydrocyanic acid when triturated with 
water. 



AMYLUM. 463 

Preparations. Dose. 

Oleum Amygdalae Amarae, U. S. P. . . . £-1 min. (0.016-0.06 c.c). 
Benzaldehydum, U. S. P. (an aldehyd pro- 
duced artificially or obtained from oil of 

bitter almond, and having the odor and 

taste of the latter) |-l min. (0.016-0.06 c.c). 

Oleum Amygdalae Expressum, U. S. P. 
Aqua Amygdalae Amarae, U. S. P. (^ per 

cent, of oil of bitter almond) 1-4 fl. dr. (4.0-15.0 c.c). 

Spiritus Amygdalae Amarae, U. S. P. (1 per 

cent, of oil of bitter almond) 5-20 min. (0.3-1.2 c.c). 

Syrupus Amygdalae, U. S. P. (1 per cent. 

of the spirit of bitter almond) 1-4 fl. dr. (4.0-15.0 c.c). 

Emulsum Amygdalae, U. S. P. (6 per cent. 

of sweet almond) 2-4 fl. dr. (8.0-15.0 c.c). 

Unguentum Aquae Rosae, U. S. P. (cold 

cream: spermaceti, 12.5; white wax, 

12 ; expressed oil of almond, 56 ; stronger 

rose-water, 19; sodium borate, 0.5). 

The expressed oil of almond also enters into the emulsion 
of chloroform and the emulsion of oil of turpentine. 

Therapeutics. — Almond is nutritive and demulcent. As 
almond flour contains no starch, it may be used, after the 
sugar and gum have been extracted from it, as a diabetic food. 
Expressed oil of almond, ointment of rose-water, and emulsion 
of almond are useful emollients. Syrup of almond is employed 
chiefly as a pleasant vehicle. Oil of bitter almond is an active 
poison. It was for a time used as a substitute for hydrocyanic 
acid, but its uncertain composition proved to be a great disad- 
vantage. It is now rarely employed except as a flavoring 
agent. 

AMYLUM, U. S. P. 

(Starch.) 

Official starch is the fecula of the seed of Zea mays, or 
Indian corn. Wheat-starch and rice-starch are also used in 
therapeutics. 

Preparation. 

Glyceritum Amyli. 

Therapeutics. — Finely powdered starch is much used as 
an absorbent and protective application in erythema intertrigo, 
or chafing. As it readily decomposes in the presence of heat 
and moisture, boric acid should be added to it as a preservative. 
The starch poultice, made by mixing starch with cold water 
and then adding boiling water until the mass is converted into 
a gelatinous paste, is sometimes employed to remove crusts in 
chronic inflammatory diseases of the skin. Starch-and-lauda- 



464 



PROTECTIVES. 



num enemata, made by adding laudanum to thin starch muci- 
lage, are often efficacious in acute dysentery and other inflam- 
matory diseases of the rectum. Starch is an antidote to iodin- 
poisoning. 

ADEPS L.ANJE, U. S. P., and ADEPS LAN^ 
HYDROSUS, U. S. P. 

(Wool-fat and Hydrous Wool-fat; Lanolin.) 

Wool-fat is the purified fat of the wool of sheep, freed from 
water, and hydrous wool-fat is wool-fat mixed with not more 
than 30 per cent, of water. Both preparations are yellowish- 
white, unctuous substances, having a faint peculiar odor. 

Hydrous wool-fat enters into belladonna ointment, stra- 
monium ointment, ointment of ammoniated mercury, ointment 
of yellow mercuric oxid, and ointment of red mercuric oxid. 

Therapeutics. — Hydrous wool-fat was introduced by Lie- 
breich, under the name of lanolin, as a vehicle for external 
medicaments. As an ointment base it is bland and unirritating, 
does not become rancid, and is miscible with twice its weight 
of water without losing its ointment-like character; but the 
claim that it has greater penetrating power than all other fats 
is not borne out by experience. Singly, it is an unsatisfactory 
base, but it sometimes makes a valuable addition to other 
bases, especially when aqueous substances are to be incor- 
porated. 

In certain skin diseases ointments containing water are ob- 
jectionable; in such cases the anhydrous preparation of wool- 
fat should be chosen. 

CETACEUM, U. S. P. 

(Spermaceti.) 

Spermaceti is a concrete fatty substance obtained from the 
head of the sperm-whale {Physeter macrocephalus). It occurs 
in pearly-white, translucent masses, odorless, and of a bland, 
mild taste. It is employed chiefly to give proper consistence 
to cerates and ointments. 

Preparation. 
Unguentum Aquae Rosae, U. S. P. (12.5 per cent.). 

OLEUM OLIViE, U. S. P. 

(Olive Oil ; Sweet Oil. ) 
Olive oil is a fixed oil expressed from the ripe fruit of Olea 



PE TR OLA TUM. 465 

europcea. It is an ingredient of diachylon ointment and sev- 
eral official oleates. 

Therapeutics. — Externally, olive oil is a useful emollient. 
With carbolic acid (5 per cent.) it makes a soothing, protective 
application for superficial burns. In scarlatina and measles 
daily inunctions of olive oil are of service in allaying irritation 
of the skin and in preventing diffusion of the scales. It may 
be employed to soften adherent crusts in such diseases as 
eczema and seborrhea. Enemata of olive oil (6 to 8 oz. — 
175.0—235.0 c.c.) are very efficacious in removing fecal con- 
cretions from the rectum. Internally, its effects are nutritive, 
demulcent, and feebly laxative. Leube and others have em- 
ployed, with good results, daily subcutaneous injections of 
olive oil (2-6 oz. — 60.0-175.0 c.c.) as a means of nourishing 
patients with stricture of the esophagus, but the treatment is 
not without danger. In one instance, at least, it was the cause 
of fatal oil-embolism. By some authorities olive oil is held in 
high repute as a remedy for gall-stones, but its value is some- 
what doubtful. Five or six ounces (1 50.0-175.0 c.c.) are given 
in the attacks of colic, and smaller doses in the intervals. If 
the drug possesses any efficacy in cholelithiasis, this may 
depend upon an antispasmodic influence exerted upon the 
common bile-duct, as Cohnheim has found large doses of the 
oil very beneficial in gastrectasis depending upon spasm of the 
pylorus from ulcer or fissure, and Weill, Duplant, and others 
have spoken highly of olive oil in lead-colic. 

PETROLATUM. 

(Paraffin; Cosmolin; Vaselin.) 

Petrolatum is a mixture of hydrocarbons, chiefly of the 
marsh-gas series, obtained by distilling off the more volatile 
portions of petroleum and purifying the residue when it has 
the desired melting-point. Three forms are official : Petrolatum 
{Petrolatum), a. yellowish mass, of the consistence of an oint- 
ment ; white petrolatum (Petrolatum album), a white mass, of 
the consistence of ointment ; and liquid petrolatum (Petrolatum 
liquidum), a colorless, transparent, oily liquid. 

Therapeutics. — Petrolatum is largely used as an emollient 
and protective dressing and as a substitute for animal and 
vegetable fats in ointments. It is bland and unirritating, and 
has little tendency to change. It probably has somewhat less 
penetrating power than lard. 

Subcutaneous and submucous injections of paraffin, as recom- 

30 



466 PROTECTIVES. 

mended by Gersuny in 1900, have been employed with gratify- 
ing results for the correction of various defects and for cos- 
metic purposes. They have been used successfully in pre- 
venting rectal and vaginal prolapse, in relieving incontinence 
of urine and of feces, in filling depressions caused by the 
removal of tissue, in correcting nasal deformities, etc. The 
paraffin should have a melting-point of from ioo° to 104 F. 
(38°-40° C), should be sterilized by boiling, and should be 
injected while warm and semisolid. The paraffin is not 
absorbed, but remains where injected and finally becomes 
encapsulated. 

GLYCERINUM, U. S. P. 

(Glycerin; C 3 H 5 (OH) 3 .) 

Glycerin is a liquid obtained from fats and fixed oils by 
saponification with alkalis or by the action of superheated 
steam. It is colorless, transparent, hygroscopic, without odor, 
and of a sweet, warm taste and a syrupy consistence. It is 
freely soluble in water and in alcohol, but insoluble in ether, 
chloroform, and oils. The dose is from 1-4 fl. dr. (4.0-15.0 c.c). 

Preparations. Dose. 

Glyceritum Phenolis, U. S. P. (20 per cent. 

of phenol). 
Glyceritum Acidi Tannici, U. S. P. (20 per 

cent, of tannic acid). 
Glyceritum Amyli, U. S. P. (plasma ; starch, 

10; water, 10; glycerin, 80). 
Glyceritum Boroglycerini, U. S. P. (50 per 

cent, of boroglycerin). 
Glyceritum Hydrastis, tJ. S. P. (each cubic 

centimeter contains I gm. of drug). 
Suppositoria Glycerini, U. S. P. (each sup- 
pository contain 45 gr. — 3.0 gm. — of gly- 
cerin). 
Gelatinum Glycerinatum, U. S. P. (gelatin 

and glycerin, of each, 100 gm. ; water to 

make, 200 gm.). 
Cataplasma Kaolini, U. S. P. (kaolin, 57.7 

parts; boric acid, 4.5 parts; glycerin, 37.5 

parts; with small quantities of methyl 

salicylate, thymol, and oil of peppermint). 
Glyceritum Ferri, Quininae et Strychninse 

Phosphatum, U. S. P 10-30 min. (0.6-2.0 c.c). 

Physiologic Action. — Owing to its avidity for water, 
pure glycerin, when applied to sensitive skin, produces con- 
siderable burning and irritation. Internally, in large doses 
(1 oz. — 30 c.c), it sometimes acts as a cathartic, probably by 



TALCUM. 467 

abstracting water from the intestinal vessels and also by stimu- 
lating peristalsis. In moderate doses glycerin has some nutri- 
tive value, inasmuch as it is largely oxidized in the body and 
protects from combustion fats and carbohydrates. When large 
amounts are injected directly into the circulation of an animal 
they cause muscular weakness, thirst, vomiting, hemoglobin- 
uria, a fall in temperature, a rapid, weak pulse, tetanic convul- 
sions, coma, and, finally, death from asphyxia. 

Glycerin possesses some power in inhibiting the growth of 
micro-organisms. 

Therapeutics. — Externally, glycerin is employed in various 
forms as an emollient. In the form of an ointment or lotion 
it is useful in chapped hands, fissured nipples, etc. It is highly 
recommended as a preventive against bed-sores. The parts 
should be bathed twice daily with warm water, carefully dried, 
and gently rubbed with the glycerin. The official cataplasm 
of kaolin is a paste of white clay and glycerin. Applied hot, 
it often makes a good substitute for the ordinary poultice. In 
inflammatory disease of the mouth, nose, and throat glycerin 
makes an excellent vehicle for other drugs. Being hygro- 
scopic, it not only tends to deplete the turgid capillaries, but it 
also serves to spread the medicament over the entire surface. 
In endometritis, uterine congestion, and subinvolution tampons 
holding glycerin and tannin afford an efficient means of secur- 
ing local depletion. In the form of a suppository or of an 
injection (2-3 fl. dr. — 8.0-1 1.0 c.c. — with 1-2 fl. oz. — 30.0- 
60.0 c.c. — of water) it is often employed with advantage to 
unload the bowel in simple constipation. 

Glycerin was at one time recommended as a substitute for 
cod-liver oil in phthisis and other wasting diseases, but it proved 
to be of little value. In diabetes it may be employed as a 
sweetening agent instead of sugar, but, as a rule, patients soon 
tire of it. 

In pharmacy glycerin is extensively used as a solvent, an 
excipient, and a preservative. 

Incompatibles. — Glycerin is explosive with powerful oxi- 
dizing agents like chromic acid and potassium permanganate. 
Undiluted mixtures of potassium chlorate, tincture of ferric 
chlorid, and glycerin are liable to explode if warmed. 

TALCUM, U. S. P. 

(Talc; Venetian Talc ; Magnesium Silicate ; Soapstone.) 

Talc occurs in grayish-green masses having a waxy luster 



46 8 PRO TECTIVES. 

and a greasy feel. It is insoluble in acids and other liquids. 
Finely powdered, it is employed as a dusting-powder in in- 
flammatory diseases of the skin, especially in erythema inter- 
trigo and acute erythematous eczema. It is usually prescribed 
with an antiseptic and an absorbent, as in the following formula : 

R Pulveris talci, ^iv (15.5 gm.); 

Pulveris acidi borici, ^j (4.0 gm.) ; 

Pulveris zinci oxidi, giij (11.5 gm.). M. 

KAOLINUM, U. S. P. 

(Fuller's Earth; Hydrated Aluminum Silicate.) 

Kaolin is a white, impalpable powder, unctuous when moist. 
Like talc, it is inert and unalterable. It is used as a protectant 
in inflammatory skin diseases, sometimes as a dusting-powder, 
but more often in the form of a paste, when ointments and 
lotions are found to be irritating. Mixed with glycerin, as in 
the official cataplasm of kaolin, and applied hot, it is employed 
as a substitute for poultices. In pharmacy it is used as a pill- 
basis for substances readily decomposed, like silver nitrate and 
potassium permanganate. 

LYCOPODIUM, U. S. P. 

Lycopodium is the spores of Lycopodium clavatum and of 
other species of Lycopodium, mosses growing in the dry woods 
of nearly all temperate countries. It is a fine, pale-yellowish 
powder, mobile, inodorous, and tasteless. It is employed in 
therapeutics chiefly as a protective and absorbent application 
to excoriated surfaces. In pharmacy it is much used to prevent 
the adhesion of pills, suppositories, etc. 

COLLODIUM, U. S. P. 

(Collodion.) 

Collodion as a solution of pyroxylin, or gun-cotton (4), in 
ether (75) and alcohol (25). It is a colorless, syrupy, highly 
inflammable liquid, having a strong ethereal odor. 

Preparations. 
Collodium Flexile, U. S. P. (collodion, 92 ; Canada turpentine, 5 ; castor 

oil, 3). 
Collodium Stypticum, U. S. P. (tannic acid, 20 ; alcohol, 5 ; ether, 25 ; 

collodion, to make 100). 
Collodium Cantharidatum, U. S. P. (Blistering Collodion : Cantharides, 

60; flexible collodion, 85; chloroform, to make 100). 



LIQUOR GUTTA-PERCHJE. 469 

Therapeutics. — Collodion was introduced into surgery by 
Schoenbein, in 1846. When applied to an exposed part it 
quickly dries and forms a thin film, which in shrinking exerts 
a constricting and compressing effect. It makes a useful pro- 
tective for abrasions, fissures, and aseptic punctures. It also 
affords an efficient means of securing antiseptic dressings on 
small wounds, especially those about the face and scalp. 
Flexible collodion makes less pressure and cracks less readily 
than plain collodion. With the addition of a little benzoin it 
makes an excellent application for fissured ?iipples y chapped 
hands, etc. A mixture of plain collodion and flexible collodion 
is often employed as a vehicle for such drugs as chrysarobin, 
pyrogallol, resorcin, etc., in the treatment of certain skin dis- 
eases, especially psoriasis, chronic eczema, lupus erythema- 
tosus, and ringworm. 

Styptic collodion is sometimes applied to small wounds to 
check capillary oozing. Cantharidal collodion is employed to 
produce vesication (see p. 440). 

LIQUOR GUTTA-PERCHA. 

(Solution of Gutta-percha; Traumaticin.) 

Solution of gutta-percha is a 9 per cent, solution of gutta- 
percha in chloroform. It has been used as a substitute for 
collodion, but it possesses no advantages over the latter. 



FLAVORING AGENTS. 

LIMON. 

(Lemon. ) 

Lemon is the ripe fruit of Citrus Linionum, a tree cultivated 
in most subtropical countries. The rind contains a volatile oil, 
and the juice, citric acid. 

Preparations. Dose. 

Limonis Cortex, U. S. P. 

Limonis Succus, U. S. P 1-4 fl. oz. (30.0-118.0 c.c). 

Oleum Limonis, U. S. P 1-5 min. (0.06-0.3 c.c). 

Tinctura Limonis Corticis, U. S. P. ... i-i fl. dr. (2.0-4.0 c.c). 

Acidum Citricum, U. S. P 5-20 gr. (0.3-1.3 gm.). 

Syrupus Acidi Citrici, U. S. P. (1 per cent.) 1-4 fl. dr. (4.0-15.0 c.c). 



470 FLAVORING AGENTS. 

The oil of lemon also enters into compound spirit of orange, 
compound spirit of ammonia, and aromatic elixir. 

Therapeutics. — Lemon-juice is especially useful in scurvy, 
both as a preventive and a curative agent. Upon what ingre- 
dient the antiscorbutic properties of the juice depend has not 
been determined; they do not appear to depend upon citric 
acid, however, as other fruits and vegetables in which this acid 
does not enter are almost equally efficacious. Lemon-juice is 
believed by some practitioners to be of value also in acute 
rheumatism. In the form of lemonade it makes a pleasant 
refrigerant drink in febrile diseases. 

Hamm, Somers, and others have found citric acid of value 
in preventing the fetid odor of atrophic rhinitis. A powder 
composed of I part of the acid with 3 parts of sugar-of-milk 
is insufflated into the nostrils two or three times daily after the 
parts have been thoroughly cleansed with an alkaline solution. 

All the preparations of lemon are largely used for flavoring 
purposes. 

AURANTIUM. 

(Orange.) 

Two varieties of the orange furnish the materials for the 
official preparations : Bitter orange {Citrus vulgaris) and sweet 
orange (Citrus Aurantium). 

Preparations. Dose. 

Aurantii Amari Cortex, U. S. P 15-30 gr. (1.0-2.0 gm.). 

Fluidextractum Aurantii Amari, U. S. P. . . ^-1 fl. dr. (2.0-4.0 c.c). 

Tinctura Aurantii Amari, U. S. P 1-2 fl. dr. (4.0-8.0 c.c). 

Aqua Aurantii Florum, U. S. P Indefinite. 

Aqua Aurantii Florum Fortior, U. S. P. 

Syrupus Aurantii Florum, U. S. P. ... Indefinite. 

Aurantii Dulcis Cortex, U. S. P I 5~3° gr- C 1 - 2 »o gm.). 

Tinctura Aurantii Dulcis, U. S. P 1-2 fl. dr. (4.0-8.0 c.c). 

Syrupi Aurantii, U. S. P. . . Indefinite. 

Oleum Aurantii Corticis, U. S. P. (ex- 
pressed from the fresh peel of either 
variety of orange) 1-5 min. (0.06-0.3 C «C«)* 

Spiritus Aurantii Compositus, U. S. P. (oil 
of orange-peel, 20 ; oil of lemon, 5 ; oil 
of coriander, 2; oil of anise, 0.5; deo- 
dorized alcohol, to make loo) .... 1-4 fl. dr. (4.0-15.0 c.c). 

Elixir Aromaticum, U. S. P. (compound 
spirit of orange, 12 ; syrup, 37.5 ; deo- 
dorized alcohol and water, to make 100) 1-4 fl. dr. (4.0-15.0 c.c). 

Bitter orange-peel also enters into compound tincture of 
cinchona and compound tincture of gentian. 



ERIODICTYON—SARSAPARILLA. 47 1 

Therapeutics. — Bitter orange-peel is a feeble stomachic ; 
but, like the sweet orange, it is employed almost exclusively 
as a flavoring agent. 

ERIODICTYON, U. S. P. 

(Verba Santa.) 

Eriodictyon is the leaves of Eryodictyon californicum, an 
evergreen shrub growing in California. It contains tannin, an 
acrid, bitter resin, and a trace of volatile oil. 

Preparations. Dose. 

Fluidextractum Eriodictyi, U. S. P. . . . 20-60 min. (1.2-4.0 c.c). 

Syrupus Eriodictyi Aromaticus (fluid ex- 
tract, with compound tincture of carda- 
mom, oil of sassafras, oil of lemon, oil 
of cloves, potassa solution, alcohol, and 
syrup) 1-4 fl. dr. (4.0-15.0 c.c). 

Use. — Eriodictyon has been used to some extent as a 
stimulant expectorant; it is chiefly valuable, however, in the 
form of the aromatic syrup, to obtund the bitterness of 
quinin. The aromatic syrup is incompatible with acids. 

SARSAPARILLA, U. S. P. 

Sarsaparilla is the root of Smilax officinalis and of other 
species of Smilax, climbing evergreens growing in swampy 
forests in Central and South America. It contains several 
glucosids of the saponin class. 

Preparations. Dose. 

Fluidextractum Sarsaparillae, U. S. P. . . \-2 fl. dr. (2.0-8.0 c.c). 
Fluidextractum Sarsaparillae Compositum, 

U. S. P. (sarsaparilla, 75 ; glycyrrhiza, 

12; sassafras, 10; mezereum, 3; with 

glycerin, 10 ; alcohol and water, to make 

100) ^-2 fl. dr. (2.0-8.0 c.c). 

Syrupus Sarsaparilla? Compositus, U. S. P. 

(fl. ext. sarsaparillae, 20 ; fl. ext. glycyr- 
rhiza, 1.5 ; fl. ext. senna, 1.5 ; sugar, 65 ; 

oil of sassafras, oil of anise, oil of gaul- 

theria, of each, 0.02 ; water, to make 100) 1-4 fl. dr. (4.0-15.0 c.c). 

Uses. — Sarsaparilla has been employed for more than three 
hundred years as an alterative in syphilis and tuberculosis, but 
its beneficial effects in these diseases are very doubtful. It is 
chiefly useful in the form of the compound syrup as a vehicle 
for potassium iodid and mercury. 



472 FLAVORING AGENTS. 

LAVANDULA. 

(Lavender.) 

Lavender is the flowers of Lavandula officinalis, a shrub in- 
digenous in southern Europe. It contains a volatile oil, 
tannin, and resin. 

Preparations. Dose. 

Oleum Lavandulae Florum, U. S. P. . . . 1-5 min. (0.06-0.3 c.c). 

Spiritus Lavandulae, U. S. P \-\ fl. dr. (2.0-4.0 c.c). 

Tinctura Lavandulae Composita, U. S. P. 

(oil of lavender, with oil of rosemary, 

cinnamon, cloves, nutmeg, and red saun- 

ders) i-i fl. dr. (2.0-4.0 c.c). 

Uses. — The preparations of lavender are used solely for 
their agreeable flavor. 

The compound tincture is an ingredient in Fowler's solution. 

ROSA. 

(Rose.) 

Rose is official as the dried petals of Rosa gallica, a species 
of red rose largely cultivated in western Asia and southern 
Europe. The chief constituents are a volatile oil, tannin, 
sugar, and mucilage. The official oil of rose is distilled from 
the fresh flowers of the Damascus rose {Rosa damascena). 

Preparations. 

Fluidextractum Rosas, U. S. P. 

Syrupus Rosae, U. S. P. (12.5 per cent, of the fluid extract). 

Mel Rosae, U. S. P. (12 per cent, of fluid extract in clarified honey). 

Confectio Rosae, U. S. P. (red rose, 8; sugar, 64; honey, 12 ; stronger 

rose-water, 16). 
Oleum Rosae, U. S. P. (attar of rose). 

Aqua Rosae Fortior, U. S. P. (water saturated with oil of rose). 
Aqua Rosae, U. S. P. (stronger rose-water and distilled water, equal 

volumes). 

Rose also enters into blue-mass, compound iron mixture, 
pills of aloes and mastic, pills of aloes and iron, and ointment 
of rose water. 

Use. — The preparations of rose are used as agreeable vehicles. 

SACCHARUM, U. S. P. and SACCHARUM LACTIS, 

U. S. P. 

(Cane-sugar or Sugar and Sugar-of-milk or Lactose.) 

Cane-sugar is the refined sugar from sugar-cane (Saccharunt 



LE VUL OSE—BENZOSULPHINID UM. 473 

officinaruin) y from various species of broom-corn {Sorghum), 
and from one or more varieties of sugar-beet (Beta vulgaris). 

Preparation. 
Syrupus, U. S. P. 

Cane-sugar also enters into the various compound syrups, 
the various troches, several mixtures, and numerous other 
preparations. It is employed exclusively as a sweetening 
agent, a preservative, and a vehicle or excipient. 

Sugar-of-milk is the sugar obtained from the whey of cow's 
milk. It is harder, less soluble, and less sweet than cane- 
sugar. It is used largely as a diluent for powders. It has 
some merit also as a diuretic in cardiac dropsy. 

LEVULOSE. 

(Fruit-sugar; Fructose.) 

Levulose is a saccharine substance found in most sweet 
fruits, together with grape-sugar, and prepared artificially by 
hydrolysis from cane-sugar or from inulin, a starchy body 
contained in inula or elecampane. It occurs as a thick, syrupy 
liquid or as a coarse, granular powder, and is almost as sweet 
as cane-sugar. It was recommended by Kulz, in 1874, as a 
sweetening agent and as a carbohydrate food in diabetes. 
According to Solis-Cohen, Saundby, Tyson, and others, a 
moderate amount (8-1 2 dr. — 31.0-46.0 gm. daily) can be taken 
by most patients with impunity. 

BENZOSULPHINIDUM, U. S. P. 

( Benzosulphinid ; Saccharin. ) 

Saccharin is a principle prepared from the coal-tar deriva- 
tive, toluene. It is a light, white, crystalline powder, odorless, 
and possessing 400-500 times the sweetening power of cane- 
sugar. It is soluble in 250 parts of water, more so in alcohol 
and in glycerin, and readily so in alkaline solutions. With 
solution of sodium bicarbonate it forms a soluble sodium salt, 
soluble saccharin. Saccharin is chiefly useful as a substitute 
for sugar when the latter is contraindicated, as in diabetes mel- 
litus. Used too freely, it has a retarding influence on diges- 
tion and general metabolism. One grain (0.065 gm.) is suffi- 
cient to sweeten 4 or 5 ounces (120.0-150.0 c.c.) of tea or 
coffee. 



474 FLAVORING AGENTS. 

MEL, U. S. P. 

( Honey.) 

Honey is a saccharine fluid prepared by the hive-bee (Apis 
mellifera). It is a mixture of dextrose (grape-sugar) and levu- 
lose (fruit-sugar), with minute quantities of wax, formic acid, 
volatile oil, and coloring-matter. 

Preparations. 
Mel Depuratum, U. S. P. (clarified honey). 
Mel Rosse, U. S. P. 
Confectio Rosae, U. S. P. 

Uses. — Honey is demulcent and feebly laxative, but it is 
prescribed chiefly as an excipient. 

Wild cherry, licorice, balsam of Tolu, and many 
volatile Oils are also largely used for flavoring purposes. 



REMEDIAL MEASURES OTHER THAN 
DRUGS, 



ELECTRICITY. 

The true nature of electricity is still unknown ; like the other 
great forces of nature, it must be studied in the light of its 
various manifestations. Gilbert first employed the term to 
designate the phenomena of attraction and repulsion which 
result when amber (electrum) and similar substances are briskly 
rubbed. Electricity produced in this simple way — by the rub- 
bing together of certain substances — is termed frictional or 
static electricity or franklinism. 

When two dissimilar metals like copper and zinc are placed 
in a corrosive fluid and united outside by a loop of wire, the 
resulting chemical action is attended with the production of an 
electric current, and to this manifestation of electricity the term 
galvanism is applied. The vessel, its contained fluid, and 
connected elements together constitute a galvanic cell. The 
union of several cells forms a battery. The energy which starts 
the electric current is termed the electromotive force, and it is 
always the same in quantity for the same materials at the same 
temperature, and is entirely independent of the size and shape 
of the plates and of the distance between them. The current 
is generated at the surface of the element or plate more easily 
corroded, which in the above illustration is the zinc, and passes 
through the fluid to the element or plate less affected, — that 
is, the copper, — and from the external end of the copper it 
passes through the wire loop back again to the external end 
of the zinc, thus completing a closed circuit. As the external 
end of the copper is constantly giving off electricity, it is 
termed the positive pole, or anode ; and as the external end of 
the zinc is constantly receiving electricity, it is termed the 
negative pole, or cathode. 

It is evident that the electromotive force will more than 
represent the strength of the current, for all substances offer 
more or less resistance to the passage of electricity. The 
resistance within the cell is termed the internal resistance, and 
that without the cell the external resistance. The amount of 
internal resistance will depend upon the character of the inter- 

475 



476 REMEDIAL MEASURES OTHER THAN DRUGS. 

vening fluid, the size of the plates, and their proximity. The 
larger the plates and the closer they are to each other, the less 
becomes the internal resistance. The external resistance 
depends upon the length, diameter, and character of the con- 
ductor. The law of the relation of the current-strength to the 
electromotive force and to the resistance was discovered by 
Ohm, in 1827: The strength of an electric current passing a 
section of the conductor in a unit of time is proportional to the 
whole electromotive force, and inversely proportional to the sum 
of all the resistances in the circuit. Representing the current- 
strength by C y the electromotive force by E y the internal 
resistance by Ir, and the external resistance by Er y the law 
may be expressed by the following formula : 



C 



Er -f Ir 



The unit of resistance is termed an ohm ; the unit of electro- 
motive force, a volt ; and the unit of current-strength, an 
ampere. As the last is too large a unit for medical purposes, 
Xwo" of an ampere, or a milliampere y is employed instead. 

An electromotive force of one unit acting upon a conductor 
offering one ohm of resistance will set up in that conductor a 
current of one ampere. 

The current-strength of a battery can be increased in three 
ways : (1) By diminishing the external resistance; (2) by 
diminishing the internal resistance ; and (3) by increasing the 
number of cells. When the external resistance is a fixed 
quantity, which is often the case, the current-strength can still 
be increased in one of the two remaining ways ; but when the 
external resistance is very great, as in the case of the human 
body, in which it is about 3000 ohms, the gain secured by 
enlarging the plates and lessening the distance between them 
is but trifling, and the current-strength must, therefore, be 
increased by multiplying the number of cells. 

When the external resistance is slight, as in the galvano- 
cautery, in which the current has only to render a piece of 
wire incandescent, the internal resistance becomes highly 
important, and much is gained by reducing it to a minimum. 
It follows, therefore, that a battery designed for such a pur- 
pose should consist of a few cells with large plates placed very 
near one another. The same principles likewise apply to the 
construction of batteries intended for electrolytic work. 

Of the accessories to a battery, the most important are the 
galvanometer, rheostat, and electrodes. 



ELECTRICITY. 477 

A galvanometer is an instrument for measuring the current- 
strength. 

A rheostat, or resistance-coil, is an appliance for placing in 
the circuit a known resistance; by it the external resistance 
can be increased to any extent and kept uniform. 

Electrodes are appliances of various sizes and shapes placed 
at the pole-ends so that the current can be conveniently trans- 
ferred to the body. 

Faradism, or Induced Electricity. — This manifestation of 
electric force depends upon the power which a galvanic current 
possesses, while passing through one conductor, of inducing 
momentarily a current in an overlying conductor. The in- 
duced current is instantaneous, and appears only at the making 
or breaking of the galvanic current. Moreover, it flows in a 
direction opposite to that of the galvanic current when the 
latter is made, and in the same direction when it is broken. 
By rapidly making and breaking the primary current a powerful 
to-and-fro current is induced in the overlying conductor. A 
faradic battery consists of cells for generating the galvanic 
current; a primary coil, consisting of a few turns of coarse 
insulated wire inclosing a coil of soft iron ; a secondary coil, 
composed of many turns of very fine wire surrounding the 
primary coil, but not touching it ; and a mechanical device for 
slowly or rapidly making or breaking the current in the primary 
circuit. 

The current derived from the primary coil is termed the 
primary current ; like the galvanic, it flows in one direction 
and affords a positive and a negative pole. It differs, however, 
from the galvanic current in being reinforced by the turns of 
the coil. The current derived from the secondary coil is 
termed the secondary current, and, since it is ever changing the 
direction of its flow, it cannot furnish negative and positive 
poles. 

Physiologic Action of Electricity. — When a powerful 
uninterrupted galvanic current is applied to sensitive parts of 
the body through moistened electrodes, it produces at the 
points of contact severe burning pain, redness, and, finally, 
under the negative pole, vesication. These phenomena are 
the result of electrolytic changes induced by the current. 
When the circuit is broken and again when it is closed active 
muscular contraction occurs ; in the interval between opening 
and closure, however, the muscle is quiescent. 

When the negative pole, or cathode, is placed over the 
nerve supplying a muscle, and the positive pole, or anode, over 
some indifferent point, as the sternum, and a weak current is 



478 REMEDIAL MEASURES OTHER THAN DRUGS. 

used, a contraction of the muscle occurs on closing the circuit, 
but none on breaking it. When the positive pole is placed 
over the nerve and the negative over the sternum, and a some- 
what stronger current is employed, a contraction occurs when 
the circuit is broken. With a still stronger current a contrac- 
tion occurs also when the circuit is closed. When the positive 
pole is over the nerve, contractions on breaking the circuit 
occur only with currents of very great power. 

The following table represents the relative strengths of the 
various contractions in normal muscles, 1 being the strongest : 

1. Cathodal closing contraction (CaCIC). 

2. Anodal opening contraction (AnOC). 

3. Anodal closing contraction (AnCIC). 

4. Cathodal opening contraction (CaOC). 

When one pole is placed over the sternum and the other 
over the motor point of the muscle, — i. e. y the point of entrance 
of its motor nerve, — contractions are obtained with weaker 
currents and the reactions are somewhat changed, the anodal 
closing contraction becoming stronger than the anodal opening 
contraction. 

Effect of the Faradic Current. — When a strong induced 
current is applied to a part it causes a tingling sensation, fol- 
lowed by numbness. If a dry metallic electrode be used, the 
contact excites severe pain. When the current is passed 
directly through a muscle, it causes a continuous or tetanic 
contraction which lasts until the current ceases to flow. 

The Reaction of Paralyzed Muscles to Electric Currents. 
— When a galvanic current is applied to a paralyzed part, the 
reactions may be normal, they may be altered quantitatively, 
i. e. y increased or diminished, — or they may be altered quali- 
tatively. 

A normal response of the muscles to both galvanic and 
faradic currents often occurs in hysteric paralysis and in 
paralysis of cerebral origin. An increased response to both 
currents without qualitative change indicates a state of irrita- 
tion or hypersensitiveness of the spinal centers or peripheral 
nerves, and may be observed very early in apoplectic hemi- 
plegia, very early in neuritis, and in some cases of hysteria. 
A diminished response to both currents without qualitative 
change is observed in pseudomuscular hypertrophy, in pro- 
gressive muscular atrophy until a late period of disease, and 
sometimes in neuritis after the very early stage, and before 
much degenerative change has taken place in the nerve-trunk 
or muscles. 



ELECTRICITY. 



479 



Reaction of Degeneration (DeR). — This consists in a 
qualitative change in the electric reaction, a reversal of that 
occurring in normal muscle. It is obtained only with the gal- 
vanic current when the electrode is placed over the muscle, — 
not its motor nerve or motor point, — and is observed in para- 
lyzed muscles which are in certain stages of degeneration on 
account of a lesion of their supplying nerves or of that por- 
tion of the spinal cord from which those nerves have their 
origin ; or, in other words, when the muscles are cut off from 
the trophic influences which emanate from the ganglionic cells 
in the gray matter of the spinal cord. In such cases the 
muscles fail to respond to the faradic current, but still respond 
to the galvanic current. The responses, however, instead of 
being immediate and short as in health, are sluggish and per- 
sistent, and, moreover, are reversed in their sequence. Thus, 
the anodal closing contraction may equal, or at a later period 
may exceed, the cathodal closing contraction, and the cathodal 
opening contraction may equal or exceed the anodal opening 
contraction. These reactions may be expressed as follows : 

AnCIC equals or is greater than CaClC. 
CaOC equals or is greater than AnOC. 

Administration. — The galvanic current may be applied in 
various ways. In the stabile or continuous method the elec- 
trodes are applied firmly over the desired points and are kept 
stationary while the current is flowing. In the labile method 
an electrode is placed over an indifferent point, while the other 
is slowly stroked over the affected part, but not lifted from the 
skin. In this way contraction of all parts of a muscle may be 
secured. In the interrupted method one electrode is kept 
stationary while the other is alternately applied and removed, 
or both electrodes are kept stationary while the current is 
interrupted by means of a mechanical device in the handle of 
one of the electrodes. Finally, the electrodes may be kept 
stationary while the current is repeatedly reversed by making 
pole-changes in the metallic circuit. By interrupting and 
reversing the current very decided stimulant effects may be 
secured. In all applications of the galvanic current the elec- 
trodes should be well moistened with warm water. 

In applying the faradic current to muscles, one large elec- 
trode should be placed over an indifferent point and the other 
over the body of the muscle to be treated, or, if a more 
decided action is desired, over the motor point of the muscle. 
Both electrodes should be well moistened. If the peripheral 



480 REMEDIAL MEASURES OTHER THAN DRUGS. 

ends of the cutaneous nerves are to be treated, the skin should 
be thoroughly dried and the current applied through a wire 
brush, the indifferent electrode only being moistened. As the 
dry skin has a very high resistance, it is necessary in applying 
the wire brush to employ a secondary coil with many turns 
(2000 or 3000) of fine wire. 

General faradization may be practised by passing one elec- 
trode slowly over the surface of the body, the other being 
held stationary ; or it may be practised by means of the elec- 
tric bath. In the latter the patient's body is immersed in warm 
water through which a current is made to pass. 

In franklinization the current is applied to the body in the 
form of sparks or a spray drawn from an electric machine of 
high potential. Such a machine should have from eight to 
twelve revolving plates of a diameter of not less than 20 
inches. 

The dosage of electricity can be estimated only very 
roughly. Two important factors are the current-strength and 
the size of the electrodes. In galvanic applications the current- 
strength can be accurately determined by means of the abso- 
lute galvanometer. The concentration or density of the cur- 
rent, however, must also be considered, and this depends 
largely upon the size of the electrodes. Thus, the larger the 
electrode, — owing to a greater opportunity for diffusion, — the 
less powerful the local effect. The current-density equals the 
current-strength divided by the surface of the electrode. We 
may express the dosage approximately, therefore, by a frac- 
tion, the numerator of which is the current-strength in milli- 
amperes and the denominator of which is the surface of the 
electrode in square centimeters. The fraction -£$, for instance, 
would indicate a current-strength of 1 milliampere and an 
exciting electrode of 20 square centimeters. 

The only practical way of measuring the strength of the 
faradic current is by means of an arbitrary scale indicating the 
relative positions of the primary and secondary coils. As the 
thickness and length of the wire used in the coils influence 
decidedly the magnitude of the current, it follows that the 
readings of such a scale are of little value in comparing the 
results obtained with different instruments. Such general 
terms as weak, medium, and strong are usually employed to 
express the strength of faradic currents. As regards static 
electricity, there is no method of measuring the strength of 
the current that has even a semblance of accuracy. 

Until we possess more accurate means of computing the 
dose of the several currents we must, perforce, be guided in 



ELECTRICITY. 48 1 

their use very largely by the sensations of the patient and the 
activity of the muscle reactions. 

The selection of the proper current cannot always be made 
offhand ; in very many cases it must be determined empirically. 

The duration of the applications in localized electrification 
should generally be from three to five minutes, and the treat- 
ment should be repeated two or three times a week, or even 
daily in acute cases. In general electrification each seance 
may last from ten to twenty minutes, and be repeated two or 
three times a week. Pain and fatigue are to be avoided. 

Therapeutics. — Electricity is employed in medicine to 
restore functional activity to peripheral nerves and muscles 
when conduction has not been completely cut off by some 
irreparable lesion; to promote general nutrition; to arouse 
the nerve-centers in states of depression ; to combat various 
sensory disturbances which are of a functional character or 
which depend upon minor lesions of the peripheral nerves or 
their centers; to effect the rapid passage of drugs through 
the unbroken skin (cataphoresis) ; to bring about the coagula- 
tion of blood in aneurysmal sacs; to favor the absorption of 
inflammatory or degenerative products ; and in the form of 
the galvanocautery, to excise or destroy hypertrophied tissues 
or morbid growths. 

Whether the good achieved by electricity, especially by 
franklinism, in functional nervous diseases is to be attributed 
to the specific action of the electricity itself, or whether it is to 
be regarded as being wholly the work of suggestion, is a 
question upon which opinion is divided. It cannot be denied, 
however, that in some of these cases, at least, the benefit derived 
is the result rather of psychologic than of physiologic effects. 

In a large group of cases the efficacy of electricity depends 
upon its power to excite muscular contraction. In apoplectic 
hemiplegia triweekly applications of a faradic current suffi- 
ciently strong to produce good contractions of the affected 
muscles are often very useful. The treatment should not, 
however, be begun until three or four weeks after the attack, 
and need not last more than five or six weeks. Contractures 
are very rarely benefited, although occasionally slight relief is 
afforded by faradization of the muscles antagonistic to those 
which are affected. 

In paralysis from lesions of the peripheral nerves, such as 
neuritis, if the damage to the nerve has not been too great, 
much may be hoped for from the use of electricity. It should 
never be employed, however, until all symptoms of irritation 
have subsided. The faradic current is to be used if the mus- 

31 



482 REMEDIAL MEASURES OTHER THAN DRUGS. 

cles respond to it. In the more severe cases in which faradic 
excitability is lost, labile and interrupted galvanic currents 
should be applied with the pole which produces the best con- 
tractions. In very severe cases with well-marked reaction of 
degeneration nothing is to be expected from electric treatment. 
In some cases of multiple neuritis the electric bath may be 
used with advantage. 

In infantile spinal paralysis electric treatment persistently 
carried out for several months is not infrequently followed by 
a restoration of power in certain groups of muscles. The 
applications should be begun about three weeks after the onset 
of the disease, and made three or four times weekly. When 
faradic contractility is lost, as is usually the case, galvanism 
should be employed, one electrode (cathode) being placed over 
an indifferent point, such as the spine, while the other (anode) 
is slowly stroked over the affected muscles. In spinal spastic 
paralysis and the progressive muscular dystrophies nothing 
can be hoped for from electricity. 

In locomotor ataxia, while electricity exerts no influence on 
the progress of the disease, it is sometimes very useful in the 
form of the faradic brush in relieving lancinating pains and 
paresthesia. J. K. Mitchell has found faradism especially bene- 
ficial also in rectal and vesical tenesmus, given with one pole 
in the rectum and in the latter altogether percutaneously. 

In the so-called idiopathic forms of neuralgia electricity 
may afford great relief. The stabile galvanic anode should be 
used first, and, failing with this, faradism should be tried, the 
current being taken from a secondary coil wound with fine 
wire 5000 or 6000 feet in length. Static electricity has also 
been used in some cases with good results. Temporary allevia- 
tion of pain can be secured by cataphoresis. A satisfactory 
method is to cover the positive pole with several layers of 
tissue-paper wet with a 10 per cent, solution of cocain, and to 
apply it over the most painful spot. With a current of from 
5 to 10 milliamperes local anesthesia can be produced in about 
five minutes. 

In neurasthenia general electrization (faradism or galvanism) 
is often a useful adjuvant to other therapeutic measures. It 
must be employed, however, with considerable circumspection, 
since in some cases the symptoms appear to be rather aggra- 
vated than relieved by the treatment. Only mild currents 
should be used, and at first the applications should not last 
longer than five or ten minutes. 

In hysteria electricity is sometimes remarkably efficacious, 
probably through its psychic effect, in dispelling certain local 



ELECTRICITY. 483 

symptoms, such as anesthesia, analgesia, pain, paralysis, and 
contractures. Faradization with the wire brush and franklini- 
zation, to which hysteric subjects are often very tolerant, are 
the currents most generally useful. General faradization, also, 
forms a part of the Weir-Mitchell treatment, which is espe- 
cially applicable to obstinate cases. 

In exophthalmic goiter galvanic treatment systematically 
carried out is sometimes followed by distinct improvement, 
especially in the tachycardia. The best results are obtained 
with weak currents, the cathode being placed over the neck 
near the angle of the lower jaw, while the anode is applied to 
the opposite side next to the lower cervical vertebrae. The 
applications should be made daily, and each should be short, 
lasting not longer than from three to five minutes. 

In chronic myalgia — lumbago, torticollis, and pleurodynia — 
faradism applied by means of the wire brush and electrostatic 
treatment are sometimes of benefit. 

In poisoning by opium and other narcotics a strong faradic 
current affords an excellent means of arousing the patient 
without increasing the exhaustion or causing any ill effects. 

The method of treating aneurysms of the aorta by means 
of a fine wire introduced through a hollow needle and coiled 
within the sac was first suggested by Charles H. Moore, in 
1864. Corradi, in 1879, demonstrated that the procedure 
could be made more effective by passing a strong galvanic 
current through the wire, thus producing more rapid and firm 
coagulation. In this country the experiments of D. D. 
Stewart 1 and of Guy L. Hunner 2 have done much to bring 
the operation into prominence. Hunner, in 1900, collected 23 
cases (17 thoracic and 6 abdominal) treated by the Moore- 
Corradi method. Four of these (17 per cent.), 3 thoracic and 
1 abdominal, were apparently cured ; 9 (39 per cent.) were 
distinctly improved ; and in 10 death was probably hastened 
by the treatment. The technic, according to Stewart, is briefly 
as follows : Asepsis, insertion into the aneurysm, where the 
sac-wall seems nearest to the surface, of an insulated hollow 
needle, through which is introduced silver wire (about No. 
27). It must be well drawn, wound on a spool, and from 3 
to 20 feet in length, according to the size of the cavity. The 
wire is then attached to the positive pole of a galvanic battery, 
the negative electrode, large and well moistened, being applied 
to the back, and a current of from 70 to 80 milliamperes 
passed for from half an hour to an hour and a half. The wire 

1 Phila. Med. Jour., November 12, 1898. 

2 Johns Hopkins Hosp. Bull., November, 1900. 



484 REMEDIAL MEASURES OTHER THAN DRUGS. 

is then cut close to the skin and sunk beneath the surface. 
In cases of thoracic aneurysms the anesthesia may be local. 
The chief dangers, according to Hunner, are from sepsis, 
rupture of the aneurysm from increase of pressure due to 
coagulation in a portion of the sac only, the entering of a 
loop of wire into the aorta, and emboli breaking from the sac- 
wall. Failure is to be expected in aneurysms with fusiform 
sacs and when there is marked general arteriosclerosis. In 
view of the gravity of the disease and the inefficiency of 
medical treatment the results so far obtained from this method 
of treatment must be considered encouraging. 

Galvanism has been employed for its electrolytic effects in 
uterine fibroma, goitre \ tonsillar hypertrophy \ etc., but the results 
achieved have not been sufficiently satisfactory to establish this 
method of treatment in the confidence of the profession. 



MASSAGE. 

The term massage is applied to systematic stroking, knead- 
ing, rubbing, and percussion of the body. One who practises 
massage is known as a masseur, if a male, and as a masseuse, 
if a female. 

Effleurage, or stroking, consists in slowly drawing the flat 
of the hand or the finger-tips over the surface of the body in 
the direction of the venous circulation. Very slight pressure 
should be made in the movements. Effleurage stimulates the 
cutaneous nerves and quickens the lymphatic and venous cir- 
culations. 

Petrissage, or kneading, is performed by grasping the tissues 
between the palmar surfaces of the hands, between the fingers 
and thumb, or between the finger-tips only, raising them 
slightly, and then rolling them while alternately tightening 
and relaxing the hold. Kneading serves to remove waste- 
products from the tissues, stimulates the circulation, and pro- 
motes nutrition. 

Friction, or rubbing, is done by making circular movements, 
under some pressure, with the palm of the hand or the finger- 
tips, the up-stroke being heavy and the down-stroke light. 
The movements should always be centripetal. Friction exerts 
about the same influence on the tissues as kneading. 

Tapotement, or percussion, consists in delivering, with the 
palm of the hand, the ulnar surface of the hand, or the tips of 
the fingers, rapid rhythmic blows. Palmar percussion is used 
chiefly on the limbs ; ulnar percussion on the chest and back ; 



MASSAGE. 485 

and digital percussion on small uneven surfaces like the face. 
Percussion acts as a nerve and muscle stimulant. 

General Massage. — When general massage is to be prac- 
tised, the operator begins at one extremity, generally a leg, 
and applies to each in turn friction, kneading, palmar percus- 
sion, and palmar stroking. After the limbs, the chest receives 
friction, kneading, ulnar percussion, and palmar stroking. 
Next the abdomen is treated, deep friction and kneading being 
applied over the entire surface, and palmar stroking along the 
course of the ascending, transverse, and descending colon. 
Finally, vigorous stroking is applied over the spine from above 
downward, and the muscles of the back are subjected to fric- 
tion, kneading, and ulnar percussion. In some cases various 
movements, such as flexion, extension, circumduction, etc., 
intended to secure passive exercise of the muscles, are a 
valuable adjuvant to general massage. 

Generally, massage is best given in the forenoon, about an 
hour after breakfast. It should never be given on an empty 
stomach. At first the seances should not last more than fifteen 
or twenty minutes, but later they may be extended with advan- 
tage to an hour. To secure the best results the operation should 
be repeated daily. The patient should be recumbent and loosely 
wrapped, so that the hands of the operator may be applied di- 
rectly to the skin. The room should be free from drafts, and 
the temperature of the atmosphere about 70 ° F. (21.1 C). 
After the treatment the patient should be warmly covered and 
left to rest for from twenty minutes to an hour. 

Unless the patient's skin is very harsh and dry or is unduly 
sensitive, the masseur need not use a lubricant for the hands ; 
if, however, one is desired, cocoanut oil or cold cream is prob- 
ably the best. 

The effects of general massage in individuals who are 
required to be at rest are much the same as those of active 
exercise in persons who are able to be about. Thus, the 
immediate effects are a sense of tiredness without exhaustion 
and an agreeable feeling of drowsiness. The general circula- 
tion is first quickened and then slowed, the waste-products 
are squeezed out of the tissues, and the activity of the lymph- 
flow is increased. Later, massage whets the appetite, favors 
digestion, tends to secure restful sleep, stimulates metabolic 
activity, and promotes general nutrition. 

Therapeutics. — In the paralysis following cerebral hemor- 
rhage, acute poliomyelitis, and neuritis massage is of great 
value in maintaining the nutrition of the affected muscles ; 
even when power is hopelessly lost, it tends to retard the 



486 REMEDIAL MEASURES OTHER THAN DRUGS. 

development of contractures. Mechanical treatment, however, 
should not be instituted in these cases until all signs of irrita- 
tion have subsided. In neuralgia and sciatica local massage is 
a useful adjuvant to other measures. 

Writers' cramp and other occupatio?i spasms are best treated 
by rest, massage, and galvanism. 

In sprains rapid relief is afforded by soaking the part in hot 
water for half an hour, then practising massage, and subse- 
quently applying a firm bandage. The treatment should be 
instituted immediately after the accident. For the first ten or 
fifteen minutes the massage should consist of light digital 
stroking applied in a centripetal direction above and below the 
affected joint, the latter not being touched ; after this, however, 
gentle friction may be applied directly to the inflamed tissues. 
The treatment should be repeated two or three times daily. 

Massage is often serviceable in hastening the absorption of 
inflammatory exudation and in imparting suppleness to the 
affected joints, in traumatic arthritis, luxations , synovitis , chronic 
articular rheumatism , chronic gout y and rheumatoid arthritis. 
In acute rheumatism and acute gout manipulations are contra- 
indicated while the acute symptoms are present. 

In chronic constipation the result of intestinal atony, abdom- 
inal massage systematically practised is a most effective remedy. 

In hysteria and neurasthenia passive movements afford a 
valuable means of securing the benefits of exercise without 
the expenditure of strength. They are an important element 
in the Weir-Mitchell treatment, which includes also isolation, 
the administration of readily assimilable food in large quanti- 
ties, and electricity. In chronic heart-disease, diabetes, obesity y 
and severe anemia, when the patient is unable to take active 
exercise, massage is a great help in stimulating metabolic 
processes and in improving the general nutrition. 

Contraindications. — Massage should not be employed in 
any disease that is attended with fever. In pregnancy abdom- 
inal manipulation is contraindicated, although the treatment 
may be applied to other parts of the body up to the first stage 
of labor. Inflammatory diseases of the skin and processes 
attended with suppuration also forbid massage. 

MOVEMENT THERAPY FOR LOCOMOTOR 
ATAXIA. 

The treatment of locomotor ataxia by exercises intended to 
reeducate the muscles to perform coordinated movements, 
first described by Frenkel in 1890, has won for itself the sup- 



MOVEMENT THERAPY FOR LOCOMOTOR ATAXIA. 487 

port of many distinguished neurologists. Properly carried out, 
it may serve to keep patients on their feet for several years, 
when otherwise they might become bedridden, or it may serve 
even in getting them about again when they have been unable 
to walk for a long period, perhaps many months. 

For exercising the upper extremities the following directions 
are given : Sit in front of a table, place the hand upon it, then 
elevate each finger as far as possible ; raising the hand slightly, 
extend and then flex each finger and thumb as far as possible ; 
do this with the right and then with the left hand. Touch 
with the end of the thumb each finger-tip separately and accu- 
rately ; then touch the middle of each phalanx with the tip of 
the thumb. Sit at the table with a large sheet of paper and a 
pencil ; make a dot at each corner of the paper and one in the 
center, and draw lines from the corner dots to the center dot, 
first with one hand and then with the other. Put ten coins on 
the paper, pick them up, and place them in a single pile, first 
with the right and then with the left hand. 

For the body and legs, the following are sample exercises : 
Sit in a chair, rise slowly to erect position without the help of 
cane or arms of chair ; then sit down slowly ; stand with cane, 
feet together ; advance left foot and return it with exactness to 
original position ; then the same with right foot. Walk slowly 
ten steps forward and five back with help of canes. Stand 
without cane, but with the feet a little apart and the hands on 
the hips ; in this position stoop down by flexing the knees, and 
rise slowly. Stand without cane with the feet separated ; raise 
the hands from the sides above the head ; carry them down- 
ward and forward, and try to touch the toes. Walk along a 
fixed line on the floor by the help of a cane, placing each foot 
in turn on the line ; then repeat without using the cane. 

When the patient is confined to bed, the exercises must be 
taken in a recumbent position. He is required to flex, extend, 
abduct, and adduct each leg separately and then both simul- 
taneously. He is asked to place the heel of one foot on the 
big toe of the other foot, and then on various points from the 
ankle to the knee. He may be called upon to follow alter- 
nately, first with one foot and then with the other, lines drawn 
upon a small blackboard placed at the foot of the bed (Rhein). 

To secure good results from Frenkel's treatment, the fol- 
lowing points should be borne in mind : The exercises must 
not be applied in a routine manner ; they should be carefully 
adapted to the particular needs of each patient. Each move- 
ment should be made slowly and deliberately, with the greatest 
possible exactitude, and repeated three or four times, first with 



488 REMEDIAL MEASURES OTHER THAN DRUGS. 

the eyes open and then with the eyes closed. Owing to the 
benumbing of the sense of fatigue in tabetic patients, great care 
must be exercised to guard against exhaustion. The seances 
should not last longer than ten or fifteen minutes, and at first 
no more than two should be allowed a day. After the exer- 
cises the patient should lie upon his back until completely 
rested. Gymnastics of all kinds are to be forbidden during the 
treatment. For the first week or two, at least, the movements 
should be done under the direct supervision of the physician 
himself or a trained assistant. The duration of the treatment 
will depend largely upon the degree of the motor disturbances 
present, but in any case it should not be less than several 
months. Even when the exercises appear to be no longer 
necessary, they should be resumed at frequent intervals. 

Contraindications. — According to Frenkel, the treatment 
is absolutely contraindicated in acute cases. As vision is 
essential in performing the various movements, blindness is 
also a contraindication. Raichline further adds that the patient 
should possess a certain amount of energy and intelligence, 
that sensation should not be absolutely lost, and that arthrop- 
athies and spontaneous fractures should not be present. 



THE SCHOTT OR NAUHEIM TREATMENT. 

The treatment of chronic heart-disease carried out by the 
brothers Schott at Nauheim, Germany, consists of bathing in 
natural effervescent baths and of graduated exercises. The 
waters of Nauheim have a temperature of from 86° to 95 ° F. 
(3°°~35° C.), and are very rich in carbonic acid and in min- 
eral ingredients, especially sodium chlorid and calcium chlorid. 
The baths first prescribed have a temperature of from 95 ° 
to 90 F. (35°-32° C), contain about 1 per cent, of sodium 
chlorid and o. 1 per cent, of calcium chlorid, and are free from 
carbonic acid gas. The patient is directed to remain in the 
water not more than five or ten minutes. The duration of the 
baths and their salinity are gradually increased, while their 
temperature is gradually lowered. Eventually, after the lapse 
of a week or two, baths containing carbonic acid gas, and 
about 3 per cent, of sodium chlorid and 0.3 per cent, of cal- 
cium chlorid are taken, the temperature of the water being 
reduced as low as 8o° F. (28 C). After the bath the patient 
is well rubbed and allowed to rest for an hour. 

Artificial baths may be prepared at home in imitation of 
those at Nauheim. At the beginning of the treatment the 
bath should contain 1 pound (454.0 gm.) of sodium chlorid 



THE SCHOTT OR NAUHEIM TREATMENT. 489 

and 1 J ounces (45.0 gm.) of calcium chlorid for every 10 gal- 
lons (38.0 L.) of water, and the temperature of the water 
should be from 95 to 90 F. (35°-32° C). 

The baths may be given every other day or every day, their 
duration being gradually prolonged from five or ten minutes 
to fifteen or twenty minutes. With the increased duration of 
the baths their temperature is gradually lowered until a mini- 
mum of 8o° F. (28 C.) is attained, and their salinity is gradually 
increased until a maximum of 3 pounds (1360.0 gm.) of sodium 
chlorid and 4J ounces (140.0 gm.) of calcium chlorid to every 
10 gallons (38.0 L.) is reached. 

The plain saline baths are to be followed by effervescent 
baths. The latter may be prepared artificially by dissolving 
in the saline baths 2 ounces (60.0 gm.) of sodium bicarbonate 
for every 10 gallons (38.0 L.) of water, and then adding very 
slowly 3 ounces (90.0 c.c.) of hydrochloric acid which has 
been previously well diluted. The amount of soda and acid 
may be gradually increased until that of the former reaches a 
maximum of 8 ounces (245.0 gm.), and that of the latter a 
maximum of 12 ounces (355.0 c.c). 

A more convenient method of generating the carbonic acid 
is by using prepared tablets of sodium bisulphate with an acid 
reaction and powders of sodium bicarbonate. 

The effect of the baths is to diminish the pulse-rate, to in- 
crease the force and volume of the pulse, to lessen the fre- 
quency of the respirations, to increase the secretion of urine, 
and, in cases of cardiac dilatation, to diminish the area of car- 
diac dulness. The theory of August Schott is that the good 
effects of the baths are largely the result of a reflex stimula- 
tion of the heart through excitation of the cutaneous nerves. 

The exercises consist of a series of simple movements of 
each limb and of the trunk, which are gently resisted by the 
hand of the attendant. Massage may also be added to the 
gymnastics with good results. It is highly important in car- 
rying out the exercises to avoid fatigue. The slightest sug- 
gestion of dyspnea or of cyanosis is to be regarded as a signal 
for discontinuing the treatment. The effects of the exercises 
are very similar to those produced by the baths. It has been 
suggested that these effects are also brought about reflexly, a 
centripetal influence being exerted by the muscular contrac- 
tions upon the ganglionic centers of the heart. 

Broadbent, however, is of the opinion that "the baths or 
resisted movements give rise to a physiologic dilatation of the 
cutaneous capillaries or muscles respectively, so that the resist- 
ance to the onward movement of blood is lessened, and the left 



490 REMEDIAL MEASURES OTHER THAN DRUGS. 

ventricle, thus relieved, is able to complete its systole. At the 
same time, from the moderate and gentle character of the 
exercises, compression of the veins, such as occurs in severe 
muscular exertion, driving on the blood to the right ventricle 
and causing dyspnea, does not take place. There is thus a 
transfer of blood from the venous to the arterial system, which 
is the reverse of the tendency in most forms of heart disease." 

Without doubt, the Schott treatment, especially when it is 
carried out at Nauheim, is frequently followed by brilliant 
results. It is not applicable, however, to every case of heart- 
disease ; neither is it entitled to supplant the older and ap- 
proved methods of treatment. At most, it should be regarded 
as no more than a valuable auxiliary to rest, diet, and drugs. 
It must be admitted, too, that home treatment with artificial 
baths and resistance exercises, while not wholly wanting in 
efficacy, is much less beneficial than a course of treatment at 
Nauheim. Change of air and scene, the regulation of the 
mode of life of the patient, rest, and quiet unquestionably con- 
tribute largely to the success which has been achieved at this 
celebrated German spa. 

The treatment is chiefly applicable to cases of cardiac dilata- 
tion in which there is but slight degeneration of the myocardium. 
The contraindications are advanced degeneration of the myo- 
cardium, pronounced arteriosclerosis, and aneurysm. 

COLD. 

Cold applications may be local or general. Locally, cold 
may be applied by means of cloths wrung out of iced water, 
an ice-bag, an ice-poultice, or Leiter's tubes. Heat may also 
be abstracted by spraying the part with a highly volatile liquid, 
like ether or ethyl chlorid. An ice-bag may be made cheaply 
and conveniently by filling a pig's bladder with cracked ice, 
closing it securely, and covering it with flannel. An ice-poul- 
tice may be made by sewing up tightly in rubber cloth or a 
coarse towel crushed ice mixed with salt and sawdust, bran, 
or ground flaxseed. Leiter's tubes are flexible metal tubes 
arranged in the form of coils to fit the head, chest, abdomen, 
and other parts of the body. Two long rubber tubes are con- 
nected with the coil, one to carry ice-water from a reservoir 
placed a few feet above the patient's head, the other to conduct 
the water after its passage through the coil to a pail placed on 
the floor near the bed. Leiter's tubes are especially useful 
when the cold is to be applied continuously. 

Local applications of cold abstract heat from the part, lessen 



COLD. 



49I 



the sensibility of the peripheral nerve-filaments, cause constric- 
tion of the blood-vessels traversing the tissues exposed to the 
cold, and even affect reflexly, as Winternitz has shown, the 
vascularity of parts remote from the seat of the application. 

Cold may be applied to the whole or to a considerable por- 
tion of the body in several ways : by cold sponging, the cold 
pack, the cold douche, or the cold bath. 

Cold sponging consists in freely sponging the body with 
water at a temperature of from 8o° to jo° F. (27.5 °-2i ° C), care 
being taken not to expose more than one part at a time. The 
sponging may be made more effective by adding a little alcohol 
or vinegar to the water. 

In applying the cold pack, the bedding is first protected by 
water-proof sheeting ; the patient is then stripped and envel- 
oped in an ordinary sheet wrung out of water at a temperature 
of 70°-6o° F. (2i°-i5.5° C). The sheet should be well tucked 
in at the neck and feet, and closely adapted to all parts of the 
body. The pack is usually continued for from ten to fifteen 
minutes, and during this time it is necessary to sprinkle the 
sheet at frequent intervals with water sufficiently cool to main- 
tain a uniform temperature. 

The cold douche may be given by placing the patient, wrapped 
in a sheet, in a bath-tub, and then pouring cold water on him 
from a pail or watering-pot, or the water may be conducted 
through a rubber tube attached to a faucet and directed to 
various parts of the body. 

In the cold bath the temperature of the water may range 
from 90 to 6o°F. (32°-i5.5° C), and the immersion may last 
from a minute or two to twenty or even thirty minutes, accord- 
ing to effect desired. 

When cold is applied suddenly to a considerable portion of 
the body of a man in good health, the immediate effects are 
contraction of the cutaneous vessels, pallor of the surface, 
erection of the papillae of the skin (cutis anserina), momentary 
catching of the breath, and a feeling of coldness, with shiver- 
ing. On coming out of the bath vigorous subjects, especially 
if the skin be well rubbed, quickly experience a reaction. The 
cutaneous vessels dilate, the skin becomes flushed, and the 
patient feels warm and exhilarated. In delicate subjects, espe- 
cially if the immersion be somewhat prolonged, this reaction 
may be very imperfect or altogether wanting, in which case 
the patient may remain chilly and depressed for several hours 
after the bath. When followed by a good reaction, cold bath- 
ing exerts a powerful tonic effect. It sharpens the appetite, 
aids digestion, promotes tissue-change, and favors the elimina- 



492 REMEDIAL MEASURES OTHER THAN DRUGS. 

tion of waste-products. In pyrexia, general applications of 
cold lower the temperature, increase the flow of urine, strengthen 
and slow the pulse, and invigorate the nervous system. 

Therapeutics. — In the early stage of acute inflammation, 
especially that resulting from traumatism, a cold-water dress- 
ing often acts most happily. In diphtheria, scarlet fever, and 
acute tonsillitis the application of cold compresses or of an 
ice-bag to the throat generally affords more relief than poul- 
tices or fomentations. In chilblain ox frost-bite the intensity of 
the reaction should be moderated by rubbjng the part with 
snow or ice. In croupous pneumonia, when the temperature is 
high and the pulse strong, an ice-bag or an ice-poultice ad- 
justed over the affected lung reduces the fever, allays the pain, 
and quiets the patient. In acute dysentery Wood has found 
ice -suppositories inserted for a length of time, one after another, 
very useful in allaying tenesmus. An ice-cap or an ice-bag 
may be applied to the head with advantage in meningitis, apo- 
plexy, cerebral congestion, headache, and the delirium of fevers. 
In neuralgia dry cold sometimes affords temporary relief, but, 
as a rule, heat is more grateful. In exophthalmic goiter, parox- 
ysmal tachycardia, and symptomatic palpitation an ice-bag or a 
Leiter's coil over the precordia often exerts a sedative influence 
upon the heart. An ice-bag may also temporarily relieve dis- 
tress in aortic aneurysm, especially when the sac is superficial. 
Prior to the performance of acupuncture or of paracentesis or 
to using the actual cautery, local anesthesia may be secured by 
spraying the part with ethyl chlorid or ether, or holding over 
it for a few minutes a block of ice which has been sprinkled 
with common salt. In internal hemorrhage the application of 
an ice-bag over the affected region is a useful adjuvant to other 
measures. 

General applications of cold are used for their antipyretic 
and tonic effects. In typhoid fever and other continued fevers 
hydrotherapy has given excellent results. There is ample 
evidence to show that the mortality of typhoid fever in general 
hospitals has been reduced at least one-half under the treat- 
ment by cold bathing, so ably advocated by Brand, of Stettin. 
The details of this treatment are as follows : A bath-tub half 
full of water at 70 F. (2 1 ° C.) is kept in readiness near the 
bed, and every third hour, if his temperature is above 102. 2° F. 
(39° C.), the patient is wrapped in a sheet and carefully lifted 
into the water. While in the bath an ice-cap is kept upon the 
head or cold affusions are applied to it, and the trunk and 
limbs are vigorously rubbed, so as to bring new relays of blood 
to the surface. A stimulant is sometimes given before the 



HEAT. 493 

bath to lessen the shock. At the end of fifteen or twenty 
minutes the patient is carried back to bed and covered with a 
dry sheet and a light blanket. After he has been thoroughly 
dried, the damp coverings are removed and replaced by dry 
ones. If the patient be delicate, it is preferable to place him 
in a bath of 90 F. (3 2° C), and then gradually lower the 
temperature of the water to yo° F. (21 C). The good effects 
of the bath are : reduction of temperature, increased secretion 
of urine, marked improvement in the pulse, and lessening of 
the nervous symptoms — delirium, stupor, insomnia, and sub- 
sultus tendinum. The only contraindications are perforation, 
hemorrhage, and persistent prostration after the bath. Shiv- 
ering and blueness naturally follow the bath, and, unless very 
prolonged, are not to be considered contraindications. 

When the baths are not well borne, or the temperature 
shows no tendency to exceed 102.2 F. (39 C), cold sponging 
or the cold pack may be substituted for immersion. 

The hyperpyrexia of thermic fever or of acute rheumatism 
should be treated by immersing the patient in water containing 
crushed ice, or, better, by rubbing him with blocks of ice for 
ten or fifteen minutes. 

In neurasthenia and hysteria hydrotherapy in the form of 
the cold spray, cold douche, or cold bath, is often a valuable 
auxiliary to rest, massage, and isolation. It is very important, 
however, not to institute the treatment too abruptly, as other- 
wise it may prove harmful rather than beneficial. In chorea 
of childhood the wet-pack (8o°-70° F. — 26.5°-2i.O° C.) is 
sometimes very beneficial. 

HEAT. 

Heat may be applied in the dry or moist form, and the 
application may be local or general. Locally, dry heat is 
applied by means of hot cloths, bran-bags, water-bags or 
water-bottles, or local baths of superheated dry air. Moist 
heat may be applied by means of fomentations, poultices, or 
the douche. Hot-water baths are also applicable to certain 
limited portions of the surface of the body. Heat, locally 
applied, allays irritation of the peripheral sensory nerves, 
dilates the cutaneous vessels, increases the secretion of sweat, 
and probably, like cold and counterirritation, exerts reflexly 
some influence on the nutrition of the superficial tissues, and 
even of the underlying organs. Intense dry heat (300 F. — 
1 49 C.) not only affects the tissues to which it is directly 
applied, but also produces general diaphoresis, raises the body- 



494 REMEDIAL MEASURES OTHER THAN DRUGS. 

temperature two or three degrees, and increases the frequency 
of the pulse. 

Dry heat may be applied to a considerable portion of the 
surface of the body by means of the hot-air bath. This is best 
given with the patient in bed, a spirit-lamp being used to gen- 
erate the heat, which is conducted under the bed-clothes by 
the aid of an inverted funnel and L-shaped tube. The patient 
is stripped and wrapped snugly in a blanket, and the bed- 
clothes, over which have been spread a rubber sheet and an 
extra blanket, are slightly raised by means of a cradle, so that 
the hot air can freely enter and surround the body. The bath 
may last from fifteen to thirty minutes. The effect of a gen- 
eral application of dry heat may also be obtained in the Turkish 
bath. In this the patient is conducted through a series of 
heated apartments, the first having a temperature of ioo° F. 
(38 C.) and the last 150 F. (66° C.) or above. After perspi- 
ration has been freely established, he is thoroughly sham- 
pooed and rubbed, and then given a cold douche or a plunge- 
bath. 

The general application of moist heat may be obtained by 
means of the hot-water bath, hot-pack, or hot vapor-bath. In 
the hot-water bath the temperature of the water should be at 
first about 98 F. (37 C), but this should be raised gradually 
while the patient is still in the bath to io5°F. (40.5°C.) or 
even to no°F. (44 C). The bath may last, according to 
circumstances, from fifteen minutes to half an hour or longer. 
In the warm bath the temperature may range between 98 and 
85 F.(37°-3o°C.). 

The hot-pack is given by closely enveloping the patient in 
a blanket wrung out of hot water, covering him with two or 
more blankets and a rubber sheet, and then placing hot bottles 
at each side and at his feet. The pack may last from half an 
hour to an hour. A hot vapor-bath may be given in the same 
way as a hot-air bath, steam from a boiling kettle being con- 
ducted under the bed-clothes instead of hot dry air, or the 
steam may be generated under the bed-clothes by placing 
about the patient hot bricks or plates which have been wrapped 
in wet cloths. In the Russian bath, also, steam replaces the 
hot dry air of the Turkish bath. 

The first effects of the general application of heat are dilata- 
tion of the cutaneous vessels and the establishment of free 
perspiration. The administration of cool drinks during the 
exposure makes the application more effective by driving the 
blood from the interior to the surface of the body. There is, 
ordinarily, no marked rise in the central temperature of the 



HEAT. 495 

body, since the accumulation of heat is prevented by the free 
sweating. If, for any reason, diaphoresis does not occur, how- 
ever, the central temperature may rise somewhat — even to a 
dangerous point if the exposure be prolonged. The chief 
secondary effect of the general application of heat is increased 
elimination of effete matters from the body. Dry heat is gen- 
erally more effective than moist heat, since it induces more 
copious perspiration. 

In sudden failure of the circulation, such as occurs in shock 
and collapse, the general application of heat not only serves to 
raise the body-temperature, but also acts as a powerful cardiac 
and vasomotor stimulant. 

Therapeutics. — Heat, both dry and moist, makes a valu- 
able local application in a large number of acute inflammatory 
diseases. Generally, it may be used interchangeably with cold, 
the chief guide in the selection of one or the other being the 
feelings of the patient. Moist heat in the form of fomentations 
or hot baths is a valuable adjuvant to morphin in relaxing the 
spasm of unstriped muscles which occurs in intestinal, biliary, 
and nephritic colics, in spasmodic croup, and in retention of 
urine. Hot baths are also useful in breaking up general con- 
vulsions, especially those occurring in children. Hot foot- 
baths, through their reflex effect upon the circulation, often 
afford relief in cerebral congestion, acute coryza, and amenorrhea 
from exposure to cold. In acute and chronic parenchymatous 
nephritis hot-air baths, hot-packs, and hot-water baths are 
of the greatest service in producing diaphoresis, especially when 
there is dropsy or uremia. Mention has already been made 
(p. 488) of the efficacy of warm effervescent baths in certain 
cases of chronic heart-disease. The continuous immersion of 
the patient in a warm bath (90°-ioo° F. — 32°-38° C.) has been 
found useful in extensive burns and in some cases of phagedena. 
A course of Turkish bath's is frequently beneficial in chronic 
gout, in chronic rheumatism, and in the early stages of chronic 
Bright s disease and diabetes. 

In conditions attended with subnormal temperature, such as 
surgical shock and collapse from disease or poisoning, the gen- 
eral application of heat, especially in the form of the hot bath, 
is the most important factor of the treatment. 

The local application of intense dry heat (250°-350° F. — 
12 1 °-i 77 C.) by means of some such apparatus as was in- 
vented by Tallerman, in 1893, is often very advantageous in 
certain affections of the joints, especially in chronic synovitis, 
traumatic arthritis, sprains, tendinous inflammations, and in the 
after-treatment of fractures and luxations. In subacute and 



496 REMEDIAL MEASURES OTHER THAN DRUGS. 

chronic rheumatism it is also occasionally useful, but in rheu- 
matoid arthritis it is of little value. 



HYPODERMOCLYSIS AND INFUSION. 

Hypodermoclysis and infusion are the introduction, into the 
subcutaneous tissues and blood-vessels, respectively, of weak 
saline solutions in considerable quantities. These procedures, 
first brought prominently forward by Cantani during the 
cholera epidemic of 1892, have been found of great value in 
a number of conditions. They serve to restore vascular ful- 
ness when, from any cause, the volume of blood has been 
much reduced, to stimulate the heart, especially when cardiac 
failure is associated with arterial depletion, to dilute any toxic 
substances that may be present in the blood, and to eliminate 
toxic substances by promoting diuresis. 

In hemorrhage the injection of a saline solution affords a 
potent means of rapidly restoring the volume of blood. It 
possesses most of the advantages of transfusion without its at- 
tending disadvantages. 

Hypodermoclysis or infusion has proved very beneficial in 
many severe toxemic conditions ; thus, it has been found effica- 
cious in uremia, diabetic coma, puerperal eclampsia, septicemia y 
and pneumonia. It has given good results also in cholera, 
thermic fever, and extensive burns. In some cases of uremia, 
eclampsia, pneumonia, and thermic fever it is more effective if 
preceded by venesection. Lastly, it is exceedingly useful in 
combating the profound vasomotor paresis of shock. The 
solution usually employed for these injections is a decinormal 
salt solution (0.6 per cent.). This solution is selected because 
it corresponds closely in saline strength to the blood-serum. 
It may be prepared by adding a heaping teaspoonful of salt 
to a quart or a liter of water, boiling, and filtering. Various 
other formulae, some quite complicated, have been suggested, 
but they seem to possess no advantages over the one just 
mentioned. Plain water cannot be used for infusion on 
account of its solvent action on the blood-corpuscles. 

When the circulation is fairly active and there is no great 
emergency, hypodermoclysis should be practised in preference 
to infusion, the injection being made in the cellular tissue of 
the iliolumbar region, chest, abdomen, or thigh. The fluid may 
be introduced by means of a fountain syringe to the tube of 
which has been attached an aspirating needle of moderate 



HYPODERMOCLYSIS AND INFUSION. 497 

size. The apparatus, the hands of the operator, and the 
region selected for the puncture should be thoroughly steril- 
ized. The bag should be suspended 2 or 3 feet above the 
patient, and the solution should flow from the needle while the 
puncture is being made. The fluid should enter the tissues at 
a temperature of about 105 F. (40 C), and to insure this a 
temperature of no° F. (44 C.) should be maintained in the 
bag. The quantity of fluid required varies from 8 ounces 
(23.6.0 c.c.) to a pint (0.5 L.) in toxemic conditions, and from a 
pint (0.5 L.) to a quart (1.0 L.) or more in severe hemorrhage 
or shock. Frequently, better results are obtained by inject- 
ing smaller quantities several times than a larger quantity at 
once. In children from 2 to 4 ounces (60.0-120.0 c.c.) are 
usually sufficient. The rapidity of absorption varies with the 
state of the circulation, from twenty minutes to an hour being 
required to introduce a pint of fluid. To prevent overdisten- 
tion of the tissues, the fluid should be made to enter slowly, 
gentle friction being applied to aid absorption. 

In cases of emergency, when the circulation is very feeble 
and absorption is nearly at a standstill, intravenous infusion 
affords a more rapid means of filling the vessels and stimulat- 
ing the heart than hypodermoclysis. For infusion the appa- 
ratus may consist of a graduated glass irrigating jar, having a 
capacity of about 2 quarts (2.0 L.), and provided with rubber 
tubing. To the latter should be fitted a fine transfusion can- 
nula having a blunt, oblique tip. In great emergency a glass 
funnel, a rubber tube, and an aspirating needle will suffice. 
The reservoir should be placed about 2 feet above the patient, 
and its contents should be constantly maintained at a tem- 
perature of about no° F. (44 C), or higher (11 5 F. — 
46 C.) in cases of profound shock. The operation is per- 
formed as follows : The arm is prepared as for venesection, a 
fillet being applied securely some distance above the elbow. 
A prominent vein, preferably the median basilic or the basilic, 
is then exposed by dissection, and a ligature tied around it at 
the distal end of the wound. A second ligature is placed 
around the vessel at the proximal end of the wound, but it is 
not tied. The vein is next incised between the ligatures, and 
the cannula, while fluid is escaping from it, is carefully inserted 
into the lumen of the vein and tied in place by the second 
ligature, after which the fillet is immediately removed. From \ 
pint to 2 pints or more (236.0 — 1000.0 c.c.) may be infused, ac- 
cording to the condition of the patient. The rate of flow may 
be regulated by raising or lowering the reservoir or by means 
32 



498 REMEDIAL MEASURES OTHER THAN DRUGS. 

of a clamp attached to the tubing. At least ten minutes should 
be allowed for introducing each pint of fluid. If care be taken 
to expel all air from the tubing and cannula before inserting the 
latter, the danger of air-embolism need not be feared. 

Shortly after infusion a rigor may occur, and the pulse and 
respiration may become more rapid ; usually, however, these 
untoward symptoms gradually disappear and are followed by 
distinct improvement. 

ENTEROCLYSIS. 

By enteroclysis is meant the irrigation of the colon with 
large quantities of water, the latter being either plain or medi- 
cated, hot or cold, according to the effect desired. It is prac- 
tised for a number of purposes : To cleanse the colon ; to 
bring remedies in direct contact with the lower bowel in dis- 
eased conditions ; to raise or lower the body-temperature ; to 
stimulate the heart in shock or collapse ; to restore water to 
the blood in anhydremia ; to promote renal secretion ; to 
dilute poisonous substances that may be present in the blood ; 
to check intestinal hemorrhage; and to relieve intussuscep- 
tion. 

In some cases of indigestion with persistent constipation excel- 
lent results may be obtained by thoroughly irrigating the bowel, 
once daily or every other day, with several quarts of water at 
from 90 to yo° F. (32°-2i° C.). In acute catarrhal dysentery 
injections of a warm (103 F. — 39.5 ° C.) solution of boric acid 
(1 dram to 1 quart — 4.0 gm. to 1.0 L.), continued until the fluid 
returns from the bowel clear, often affords much relief. In 
amebic dysentery quinin (1 : 5000 to I : 2000) may be sub- 
stituted for the boric acid. In chronic dysentery no treatment 
is so generally successful as intestinal irrigation with weak 
solutions of silver nitrate (see p. 372). In enterocolitis and 
cholera infantum high enteroclysis, once or twice a day, with 
normal salt solution, is a valuable adjuvant to other thera- 
peutic measures. If the child's temperature is high, the 
water may be at 90 F. (32 C.) or lower; if, however, 
there is a tendency to collapse, the water may be at 105 ° F. 
(40 C). Cantani and others have spoken highly of entero- 
clysis with hot tannic acid solutions (2 per cent.) as an aid to 
hypodermoclysis in Asiatic cholera. 

Intestinal irrigation with hot salt solution (io5°-iio° F.— 
40°-43.5° C.) for half an hour to an hour is a potent remedy in 
shock. It may be practised also as a preventive measure if 



ENTEROCLYSIS. 499 

the condition of the patient prior to a surgical operation is 
such that shock is to be feared. Hot saline injections are 
very valuable, too, in anuria resulting from nephritis or follow- 
ing operation. In uremia they tend not only to promote renal 
secretion, but also to dilute the poisonous substances circulat- 
ing in the blood. Some practitioners speak favorably of very 
hot rectal injections (no° F. — 43. 5 C.) in hemorrhage from 
the stomach or bowel. The continuous administration of salt 
solution, drop by drop, by the rectum has given good results 
in acute peritonitis. 

Daily irrigation with cold water — yo° F. (2 1 ° C.) or lower 
— has been found quite effective in some cases of persistent 
catarrhal jaundice. Enemata of cold water (6o°-50° F. — 
I5.5°-io° C.) may be used successfully in connection with 
ice-baths to lower the temperature in thermic fever. 

Recent cases of intussusception are sometimes relieved by 
high rectal injections, but the hydrostatic pressure must not 
be too great, otherwise rupture of the bowel is liable to occur. 
The child should be anesthetized and the colon thoroughly 
but very gradually distended with warm water, the elevation 
of the reservoir not being over 3 or 4 feet. 

Enteroclysis may be practised by means of an ordinary 
fountain syringe to which has been adjusted a flexible colon 
tube, or, for children, a soft-rubber catheter (No. 20). If the 
latter be used, an extra eye should be cut in it near the tip. 
The requisite pressure is secured by elevating the water-bag 
3 or 4 feet above the patient. The return flow may be col- 
lected in a bed-pan or, better, it may be conducted, by the aid 
of a rubber sheet, into a bucket placed on the floor. The 
patient having been placed in the dorsal position with the 
hips elevated, the tube should be well lubricated and gently 
inserted from 12 to 18 inches in the adult, or 10 to 14 inches 
in the child, and the water turned on. In the adult from 1 
pint to 3 pints (0.5-1.5 L.), and in the child from ]/ 2 pint to 2 
pints (0.3-1.0 L.), of water should be allowed to enter the 
bowel, when the tube of the fountain syringe should be de- 
tached from the rectal tube, thus permitting a return flow to 
occur. 

While a long single tube used in the way just described 
gives excellent results, a double-current tube will be found far 
more convenient, especially for continuous irrigation. A good 
example of the double-current tube is the one devised by 
Dr. R. C. Kemp. 



5<DO REMEDIAL MEASURES OTHER THAN DRUGS. 

LAVAGE OF THE STOMACH. 

There are two methods of washing out the stomach — one, 
by the stomach-pump ; the other, by siphonage. The stom- 
ach-pump is simply a syringe with two apertures instead of 
one, in which are adjusted valves opening in opposite direc- 
tions. By connecting the syringe alternately at each of these 
apertures with an incompressible tube passed into the stomach, 
the gastric contents may be drawn out or fluid may be intro- 
duced into the stomach. 

Washing out the stomach by siphonage may be accom- 
plished in one of two ways : In the first a large glass funnel, 
to which is attached a rubber tube about 2 J feet (45.7 cm.) 
long, is joined through the medium of a short piece of glass 
tubing to a previously passed stomach-tube. The requisite 
amount of water, usually about a pint (0.5 L.), is poured into 
the funnel, which is then elevated sufficiently to allow the 
water to flow into the stomach. Before the funnel is empty, 
however, it is quickly depressed, so that the water is returned 
from the stomach by siphonage. The escape of the fluid from 
the stomach may be further facilitated by the application of 
gentle pressure to the epigastrium. The process should be 
repeated until the water returns clear. 

In the second method the free end of the stomach-tube is 
connected with a Y-shaped glass tube, to one limb of which 
is attached a rubber tube leading to an elevated reservoir con- 
taining water, while to the other limb is attached a rubber 
tube leading to a pail placed on the floor. By alternately 
opening and closing the two external tubes by means of 
clamps the water may be made to flow into or out of the 
stomach. 

The siphoning apparatus, on account of its simplicity and 
safety and the ease with which it can be manipulated, even by 
the patient himself, has almost completely supplanted the 
stomach-pump. The latter may be used with advantage, 
however, when the stomach contains much coarse solid 
matter or when it is necessary to remove the gastric con- 
tents very promptly and thoroughly. 

No other lubricant than water is required for the stom- 
ach-tube. The introduction of the tube is facilitated by hav- 
ing the patient breathe deeply and make repeated efforts at 
swallowing as soon as the tube reaches the posterior wall of 
the pharynx. Cocainization is sometimes employed to allay 
extreme sensitiveness of the pharynx, but it is rarely neces- 
sary. To prevent the tube from being completely swallowed, 



BLOODLETTING. 501 

it may be secured by means of a string attached to its distal 
extremity. 

Ordinarily, the water used for lavage may be unmedicated ; 
when, however, there is abundant mucus in the stomach, 2 
per cent, of sodium bicarbonate may be added with advantage. 
Potassium permanganate (1 : 5000), sodium salicylate (1 : 100), 
or sodium hyposulphite (1 : 100) may be used when there is 
excessive fermentation. 

The most important indication for lavage is retention of food 
with fermentation. Thus, in organic stenosis of the pylorus 
thorough washing of the stomach two or three times weekly, 
or every day in some cases, preferably before breakfast, affords 
great relief. In atonic dilatation with fermentation lavage is 
also efficacious. In acute food-poisoning and toxic gastritis it 
is often better to resort to the tube than to employ an emetic. 

In chronic gastric catarrh, when there is an excessive secre- 
tion of mucus it is often of service ; in other cases, however, it 
does no good, and is, according to Boas, absolutely contrain- 
dicated. Practised promiscuously in cases of simple gastric 
catarrh, it is capable of doing considerable harm and of devel- 
oping into a most pernicious habit. In super secretion of acid 
(Reichmann's disease) washing out the stomach with a solu- 
tion of sodium bicarbonate (2 per cent.) or silver nitrate 
(1 : 5000 to 1 : 2000) sometimes gives good results. Kuss- 
maul and others have found lavage of the stomach veiy bene- 
ficial in acute intestinal obstruction. In this condition it serves 
to allay vomiting, to lessen the pressure in the bowel, and to 
diminish the violent peristalsis. 

Lavage is contraindicated in peptic ulcer, in ulcerating car- 
cinoma, especially when accompanied by much bleeding, and 
in gastric catarrh associated with atrophic cirrhosis of the 
liver. It should be avoided also in advanced pregnancy, in 
aortic aneurysm, and in aged persons with marked arterio- 
sclerosis. 

BLOODLETTING. 

Bloodletting is employed both as a local and as a general 
remedial measure. As a local measure it may be practised 
by cupping or by leeching, and as a general measure by vene- 
section. 

Clipping". — There are two methods of cupping — the dry 
and the wet. In dry cupping the blood is not shed, but is 
diverted by atmospheric pressure from the deeper parts to the 
cutaneous surface. A small quantity, however, is actually 
drawn from the vessels into the cellular tissue of the skin. The 



502 REMEDIAL MEASURES OTHER THAN DRUGS. 

special instrument used for cupping consists of a glass bell with 
an aperture at its summit, through which is extracted the air 
by means of a pump or rubber ball. In the absence of such 
an instrument an ordinary tumbler will serve the purpose. A 
small piece of blotting-paper moistened with alcohol is placed 
in the bottom of the tumbler and lighted. While the paper is 
still burning the glass is inverted and applied firmly to the skin. 
The flame is immediately extinguished, and the air being ex- 
hausted, the skin in the interior rises in the cup and becomes 
of a dark-red color. To avoid burning the skin, it is necessary 
to allow all excess of alcohol to run out of the tumbler before 
igniting the paper. From one to a dozen of these cups may 
be applied, and they may be allowed to remain in position for 
from five to ten minutes. The cup can be readily removed by 
making a little pressure near the rim so as to allow air to 
enter. The same method is pursued in wet cupping, except 
that numerous small incisions are made in the skin by means 
of a scarificator before the cup is applied. As scarification 
leaves permanent cicatrices, wet cups should not be applied on 
exposed surfaces. Dry cupping is not so efficient as wet cup- 
ping, but may be practised when the patient's strength will not 
warrant an absolute loss of blood. 

I/eeclling'. — Leeches accomplish the same purpose as wet 
cups, but on account of their size and shape they can be 
applied to parts to which cups cannot be adjusted, as behind 
the ears, about joints, over the spermatic cord, and the verge 
of the anus. Each leech, according to the variety employed, 
removes from i to 3 drams (4.0-1 1. o c.c.) of blood. Leeches 
should be applied in the neighborhood of inflamed parts, not 
directly over them, and parts which are abundantly supplied 
with loose areolar tissue, like the eyelids and the scrotum, 
should be avoided. The eye may be depleted from the 
temple, and the testicle from the perineum. Before leech- 
ing, the part should be shaved and well washed, care being 
taken to remove all soap. 

Leeches may be applied with the finger or by means of 
an inverted wine-glass or pill-box. A little blood or warm 
milk smeared over the skin will generally induce them to bite 
if they are not disposed to do so. They should not be de- 
tached forcibly, but allowed to drop off themselves, or made 
to relinquish their hold by sprinkling them with salt. If 
desirable, bleeding from the bites may be encouraged by 
applying warm fomentations. Occasionally, owing to the 
presence in the tissues of a large quantity of the anti-coagu- 
lant substance secreted by the leech, the hemorrhage proves 



BLOODLETTING. 



503 



very persistent, and requires for its arrest the application of 
firm pressure, of some styptic (ferric subsulphate or alum), or 
of the actual cautery. Like scarifying, leeching leaves indel- 
ible scars. 

Local bloodletting may often be practised with advantage 
in the early stage of many acute inflammatory diseases, such 
as pneumonia, nephritis, orchitis, etc. At the onset of acute 
inflammation of serous membranes, — pleuritis, pericarditis, 
iritis, synovitis, and meningitis, — especially when the symptoms 
develop abruptly and are very severe, it may be of the great- 
est value in relieving pain and in repressing exudation. In 
acute pulmonary edema with cyanosis wet cupping is of service, 
although it is not generally so useful as venesection. 

Venesection or Phlebotomy. — The general abstraction 
of blood is accomplished by incising a vein. The patient 
having been placed in a semirecumbent position, the arm 
should be constricted a few inches above the elbow by a 
twisted handkerchief or a few turns of a roller bandage. If 
this is not sufficient to render the veins prominent, the arm 
may be rubbed for a few minutes from below upward. A 
large vein (median cephalic or median basilic) having been 
selected, it should be fixed by the thumb of the left hand 
below the point of section, and then incised by a lancet or 
bistoury in a direction oblique to the long axis of the vessel. 
The pulse should be carefully observed during the operation, 
and when it lessens in force or becomes more compressible, 
the bleeding must be suspended. The loss of blood required 
to afford relief varies in different conditions from a few ounces 
to a pint or more. To arrest the flow, it is only necessary to 
remove the fillet from the arm and to apply a small compress 
and figure-of-eight bandage. 

The cases in which venesection is indicated are those in 
which life is immediately endangered by some circulatory 
obstruction or by toxemia. In over distention of the right 
ventricle, whether from mitral disease, pneumonia, or emphy- 
sema, when there is a small, weak pulse, with cyanosis and 
orthopnea, the venous engorgement is often most promptly 
and effectually relieved by the abstraction of a few ounces 
(10-20) of blood. In cerebral hemorrhage, when the pulse 
tension is high and there are evidences of pronounced hyper- 
emia of the brain, venesection is advisable. In aortic aneur- 
ysm, when the heart-action is strong and there is severe pain, 
bleeding often affords great relief. 

In acute uremia and puerperal eclampsia venesection affords 
the most rapid means available of removing toxic substances 



504 REMEDIAL MEASURES OTHER THAN DRUGS. 

from the body. It may be practised advantageously in con- 
nection with subcutaneous and rectal injections of normal salt 
solution. 

Packard and others have found bloodletting (10-20 ounces) 
efficacious in grave cases of thermic fever. Feebleness of the 
pulse is not necessarily a contraindication, as the circulation 
often improves as the blood flows from the arm. 

ACTINOTHERAPY. 

The method devised by Finsen of treating certain localized 
diseases of the skin by means of concentrated rays of either 
sunlight or electric arc-light has met with considerable suc- 
cess. It is based upon three postulates proved experi- 
mentally by Widmark, Finsen, Bie, and Godneff : the power 
of the chemical rays to penetrate the skin ; the bactericidal 
properties of these rays ; and the power of the chemical rays 
to excite an inflammatory reaction in the skin. Finsen's ap- 
paratus is constructed to accomplish the following objects : to 
concentrate the light, to absorb or to exclude most of the 
heat-rays (ultra-red, red, and yellow) without impairing the 
chemical rays (ultra-violet, violet, and blue), to keep the skin 
cool, and to render the tissues anemic. The last is necessary 
to secure penetration of the chemical rays. 

The apparatus for sunlight consists of a lens from 8 to 15 
inches (20.0-40.0 cm.) in diameter. This lens is composed of 
two glasses, one curved and the other plain, adjusted in a 
brass ring and separated from each other by a weak ammo- 
niacal solution of copper sulphate. The blue liquid does not 
affect the chemical rays, but it cools the light by arresting the 
heat-rays. The apparatus for sunlight consists of two quartz 
lenses framed in two brass tubes, which can be moved the one 
into the other, like the two pieces of a telescope. The lenses 
are separated from each other by a space filled with distilled 
water, and in order to prevent overheating of the latter by the 
absorption of the ultra-red rays cold water is made to circu- 
late through a mantle surrounding this section of the tube. 
In both plans heating of the skin is further avoided by mak- 
ing cold water run through a hollow quartz lens, which is 
applied to the affected part with sufficient pressure to make 
the tissues anemic. 

Excellent results have been achieved by the light treatment 
in epithelioma of the skin, lupus vulgaris, and lupus erythema- 
tosus. In a few cases of alopecia areata in which it has been 
tried the results have also been encouraging. Relapses are 



R ONTGEN RA YS. 5 05 

said to be rare, and the applications are painless. Apart 
from the expense of the apparatus and the necessity of 
trained assistants, the main drawback to the light treatment 
is its duration. Daily sittings, each lasting an hour, are re- 
quired for periods ranging from several weeks to a year or 
more. 

RONTGEN RAYS. 

It has been shown conclusively that Rontgen rays exert a 
curative influence in certain diseases equal to, if not greater 
than, that of the concentrated chemical rays of light. The 
action of the two forces, however, is not exactly the same. 
Rontgen rays differ from actinic rays in having greater pene- 
trating power, in acting not only upon the skin but also upon 
the deeper structures; in having no bactericidal power; in 
being able to effect curative changes without producing any 
conspicuous inflammatory reaction ; and in rendering the tis- 
sues more sensitive to their influence the more frequently they 
are applied. The nature of the changes effected by Rontgen 
rays in animal tissues is obscure ; but some recent investiga- 
tions support the view that they stimulate autolysis and thus 
bring about the destruction of the cells. In experiments on 
mice, rabbits, and dogs, Heinke found that exposure of the 
abdomen to the rays induced transient retrograde changes in 
the nuclei of the spleen, mesentery glands, and other lymphatic 
structures. Perthes found that fertilized ova of Ascaris mega- 
locephala when exposed to -r-rays developed into imperfect em- 
bryos. Gilman and Baetjer state that chicks developed in 
eggs exposed to the rays also show deformities. Albers- 
Schonberg has demonstrated that the prolonged exposure of 
animals to the rays causes sterility by killing the spermatozoa. 
Whether the sterility is temporary or permanent he has not 
determined. Young cells seem to be more sensitive to the 
rays than old ones. This probably explains the greater influ- 
ence of the rays on new growths than on the adjacent healthy 
tissues. 

Rontgen-ray treatment has been found extremely valuable 
in superficial cancer, lupus vulgaris, and acne. It has given 
good results also in some cases of eczema, hypertrichosis, ring- 
worm, localized pruritus, blastomycosis, mycosis fungoides, and 
keloid. The chief drawbacks of the treatment are its tedious- 
ness and the possible danger of producing serious Rontgen- 
ray burns. 



506 REMEDIAL MEASURES OTHER THAN DRUGS. 

In subcutaneous , deep-seated carcinomas the effect of the rays 
is scarcely more than palliative. Pusey gives a just estimate 
of their value in the following propositions : " In all cases of 
malignant disease which have been operated on there is reason 
to urge the subsequent use of the ^r-rays as a prophylactic 
measure. In all inoperable cases of malignant disease the 
^r-rays should be tried. In such cases there is a probability 
of relieving pain and a possibility of inhibiting the progress of 
the disease." 

In leukemia and pseudoleukemia great improvement and 
even symptomatic cure very frequently follows prolonged 
treatment by Rontgen rays. Relapse, however, is to be antici- 
pated, as actual cure probably never occurs. To secure good 
results in the various diseases in which ;r-rays are indicated 
the applications should be made every two or three days, 
and continued for several weeks or months. The exposures 
should last from five to twenty minutes, the cutaneous surface 
adjacent to the diseased area being protected by lead sheath- 
ing. The appearance of even the slightest erythema is to be 
regarded as an indication for interrupting the sittings. In 
skilled hands the risk of causing .r-ray burns is slight. 

RADIUM. 

The salts of radium (bromid and chlorid) give out three 
kinds of rays, known as the alpha, beta, and gamma rays. 
Alpha rays constitute the largest part of the radiation, are 
slightly deflected by the magnet, have little penetrative power, 
and do not escape beyond the glass tube in which the radium 
is enclosed. The beta rays are strongly deviable by the mag- 
net, but in a direction opposite to that of the alpha rays, have 
greater penetrative power than the latter, and are very similar 
to the kathodal rays from a Crookes tube. The gamma rays 
exist in smaller proportion than the others, are non-deviable, 
possess great penetrative power, and are similar to the Rontgen 
rays. The activity of a specimen of radium is estimated by 
the rapidity with which it discharges a gold-leaf electroscope, 
the standard unit of time being that required for the discharge 
of such an electroscope by metallic uranium. If the specimen 
discharges the instrument in one-thousandth the time required 
by uranium, the strength is taken as iooo units. Specimens 
of high strength are generally used — anywhere from 200,000 
to 1,500,000 units. 

The therapeutic uses of radium rays have been shown to 



LUMBAR PUNCTURE. S°7 

follow the same lines as those of the Rontgen rays. Occa- 
sionally they may prove more effective than the latter, but, on 
the whole, they are distinctly less useful. They are well 
suited, however, for application to certain places, like the 
esophagus, which are inaccessible to .r-rays. As they are 
capable of producing severe burns, and even ulcers, they re- 
quire the same careful handling as the .r-rays. 

LUMBAR PUNCTURE. 

The procedure known as lumbar puncture consists in the 
removal of cerebrospinal fluid through a hollow needle intro- 
duced between the transverse processes of the lumbar verte- 
brae. Since 1891, when it was first resorted to by Quincke, for 
the relief of excessive intracranial pressure in cases of chronic 
hydrocephalus, it has been rather extensively practised not 
only as a therapeutic measure, but also for diagnostic pur- 
poses. The operation consists in introducing a needle from 5 
to 8 cm. long between the third and fourth lumbar vertebrae, 
and from 5 to 10 mm. to one side of the median line. The 
needle should be directed slightly upward and toward the 
median line. The required depth of the puncture can be de- 
termined by the sense of touch, the disappearance of resist- 
ance indicating the entrance of the needle into the cavity. In 
children the fluid is usually reached at a depth of from 2 to 
3 cm., and in adults at from 4 to 6 cm. It is better to allow the 
fluid to run from the needle than to aspirate. From 10 to 60 c.c. 
of fluid may be removed, the amount depending largely upon 
the age of the patient and the nature of the disease under 
treatment. On the occurrence of faintness, headache, or a 
change in the character of the pulse, the needle should be 
immediately withdrawn. 

The chief therapeutic indication for lumbar puncture is to 
relieve excessive pressure by the cerebrospinal fluid on the 
brain and cord. Repeated at frequent intervals, it has given 
very encouraging results in cases of acute cerebrospinal men- 
ingitis. Koplik has reported 4 recoveries in 5 cases of men- 
ingitis due to the meningococcus in which this treatment was 
employed, and Netter has reported 7 recoveries in 1 1 cases of 
purulent meningitis in which lumbar puncture was done from 1 
to 10 times and warm (104 F. — 40 C.) baths were given every 
three or four hours. In tuberculous meningitis it may be prac- 
tised as a palliative measure when the pressure-symptoms are 
very severe. In chronic hydrocephalus it is of doubtful value, 



508 REMEDIAL MEASURES OTHER THAN DRUGS. 

although in some instances it appears to have afforded tem- 
porary relief. A number of observers (Quincke, Furbringer, 
von Leyden, Carriere, and Buzzard) have found it very effect- 
ive in acute uremia. 

Jacoby has reported 2 cases of traumatic paraplegia in which 
rapid improvement followed the removal by puncture of 
bloody fluid. The operation is contraindicated in tumor of 
the brain, softening, apoplexy, and embolism. There are on 
record at least 5 cases in which sudden death was induced by 
lumbar puncture in brain-tumor. 



APPLIED THERAPEUTICS. 



ACUTE INFECTIOUS DISEASES. 

TYPHOID FEVER. 

As soon as the nature of the disease is recognized, the patient 
should be confined to bed. The room should be large and 
airy, and provided with efficient means of securing thorough 
ventilation. The temperature of the room should be main- 
tained between 65 ° and 70 F. (i8.5°-2i° C). The bed should 
be moderately firm. The mattress should be protected by a 
rubber cloth spread beneath the sheet, and the latter should 
be kept smooth to guard against the development of bed-sores. 
Even in mild cases it is advisable to have a nurse or attendant 
constantly at hand, for accidents resulting from sudden delirium 
are liable to occur. The mouth and teeth should be washed 
several times a day with a solution of boric acid (10 gr. to the 
oz. — 0.6 gm. to 30.0 c.c). The bed-pan must be used from the 
beginning until convalescence is well advanced. The stools 
and urine should be rendered innocuous before being disposed 
of. This may be done by treating the evacuation with twice 
its volume of a 1 per cent, solution of chlorinated lime or a 5 
per cent, solution of carbolic acid, and allowing it to stand in 
a covered vessel for two hours before emptying it into the 
closet. Soiled clothing should be thoroughly boiled. 

Diet. — The diet should be liquid or semisolid, unirritating, 
and easily assimilable. As a rule, milk is the best food. Most 
patients will be able to take from 2 to 4 pints (1.0 to 2.0 L.) in 
the twenty-four hours, given in portions of from 4 to 6 ounces 
(120.0- 1 7 5. oc.c.) every two or three hours. It is generally advis- 
able to dilute the milk with lime-water. If curds appear in the 
stools, the quantity of milk should be reduced. Among other 
permissible articles may be mentioned buttermilk, koumiss, 
junket, milk-whey, albumin-water, raw eggs, oyster, mutton, or 
chicken broths, chicken jelly, and consomme. Cocoa, iced tea, 
ice-cream, wine-jelly, blanc-mange, and, unless diarrhea is 
present, strained fruit-juices may be given occasionally to vary 
the monotony of the diet. Most clinicians are of the opinion 

509 



510 APPLIED THERAPEUTICS. 

that the return to solid food should not be commenced until 
the temperature has been normal a week or ten days. This 
is a good general rule, but it is open to many exceptions. In 
some cases it is advisable to wait longer than the period named 
before permitting solid food ; in others it is not only safe, but 
advantageous, to administer more substantial food some time 
before convalescence has actually begun. 

Cold water or cracked ice may be given freely, and one or 
the other should be offered to the patient several times a day 
even though he may not ask for it. It is rarely advisable to 
awaken the patient out of a sound sleep to give him either 
nourishment or medicine, but when there is stupor, he should 
be aroused at stated intervals. 

Stimulants. — Stimulants are not always required, but when 
the pulse becomes soft and the first sound of the heart indis- 
tinct, alcohol should be given tentatively, its effects being care- 
fully noted. 

Ordinarily, the best form of stimulant is whisky or brandy ; 
occasionally, however, sherry, port, or champagne may be 
better borne. At first I or 2 ounces (30.0-60.0 c.c.) of whisky 
in the twenty-four hours may be quite sufficient ; later it may 
be necessary to increase the amount to 10 or 12 ounces (295.0- 
355.0 c.c.) or more. The quantity must be determined in each 
case by the effect. If the pulse becomes stronger, the tongue 
less dry, the mind clearer, and the urine more copious under 
the administration of the stimulant, it is doing good ; if, how- 
ever, opposite effects are observed, it is doing harm, at least in 
the quantity in which it is being employed. 

Generally, the alcohol should be given with the milk, so that 
it may serve as an aid to digestion, but when the symptoms 
are very severe, it may be given also at other times. 

Special Remedies. — Various antiseptics have been recom- 
mended from time to time with the object of destroying the 
typhoid bacilli or of rendering them harmless. Thus calomel, 
corrosive sublimate, carbolic acid, iodin, chlorin water, thymol, 
/?-naphthol, salol, and guaiacol have each had their advocates. 
While certain of these agents may at times be useful in check- 
ing excessive fermentation in the intestinal canal, the evidence 
is far from convincing that they exercise any modifying in- 
fluence upon the systemic infection itself. 

While antityphoid inoculations have been practised with 
encouraging results in preventing the occurrence of typhoid 
fever, the employment of antityphoid serum as a curative agent 
has been thus far on too limited a scale for any opinion to be 
formulated as to its efficacy. 

Pyrexia. — High temperature is controlled best by the cold 



ACUTE INFECTIOUS DISEASES. 5 II 

bath or the cold pack ; these hydrotherapeutic measures not 
only reduce the temperature, but they also exert a powerful 
stimulant influence upon the nervous system and the circula- 
tion, and in many instances have a diuretic effect. Excellent 
results have been obtained by using the cold bath throughout 
the attack as often as the temperature in the mouth rises to 
102.5 ° F. (39.2 C). (See Cold.) The total mortality under 
hydrotherapy in a series of 1904 cases treated by J. C. Wilson 
in Philadelphia was 7.5 per cent. — exactly the same as that in 
1902 cases treated by F. E. Hare in the Brisbane Hospital, 
Australia. As the death-rate under the expectant treatment 
is between 14 and 15 per cent, it would appear that systematic 
cold bathing has reduced the mortality about 50 per cent. 

When the baths are inapplicable, the fever may be kept 
within safe limits by cold sponging or the cold pack. Occa- 
sionally it may be necessary to administer a small dose of 
phenacetin or of antipyrin (5 gr. — 0.3 gm.), but these drugs 
should never be used in large doses or given repeatedly. 

Heart-failure. — Cold bathing and the timely use of alco- 
hol do much to guard against heart-failure. When the ten- 
dency to cardiac failure is pronounced, strychnin may be given 
in doses of £$ - £§ gr. (0.0016-0.0032 gr.) every three or four 
hours. In severe cases the drug should be given hypoder- 
mically. Digitalis or strophanthus may also be tried, but in 
the presence of fever these remedies often prove ineffectual. 
Salt solution, given by the bowel or, if necessary, subcutane- 
ously or intravenously, sometimes renders valuable aid in com- 
bating the effects of the toxemia on the circulation. If collapse is 
threatened, ether, alcohol, or, better still, camphor (1-2 gr. — 0.06 
-0.13 gm.) may be given subcutaneously at frequent intervals. 

Diarrhea. — When the diarrhea exceeds three or four stools 
a day, efforts should be made to check it. In some cases a 
modification of the diet — reducing the quantity of milk, pep- 
tonizing the milk, or limiting the diet to albumin water alone 
— will be all that is required. In other cases it may be neces- 
sary to use a suppository or enema of opium once or twice a 
day. If the diarrhea be troublesome, bismuth subnitrate or 
silver nitrate may be given by the mouth in combination with 
opium : 

R Morphinse sulphatis, gr. j (0.065 g m -) '■> 

Salolis, gss (2.0 gm.) ; 

Bismuthi subnitratis, ^iij (12.0 gm.). M. 

Fiant chartulae No. xv. 

Sig. — One powder every three or four hours. 

R Argenti nitratis, gr. iij (0.2 gm.); 

Pulveris opii, gr. vj (0.4 gm.). M. 

Fiant pilulse xii. 
Sig. — One pill every three or four hours. 



512 APPLIED THERAPEUTICS. 

In very obstinate cases copper sulphate with opium in pill 
proves efficacious. 

Constipation. — Constipation lasting but two or three days 
requires no special treatment. Sometimes meat broths or 
strained oatmeal gruel given alternately with the milk will 
exert a nvld laxative effect. When more than a modification 
of the diet is necessary, an enema of soapy water or glycerin 
should be tried before resorting to remedies by the mouth. 
In obstinate cases small doses of calomel, of Epsom salt, or of 
castor oil may be given at short intervals until the desired 
effect is obtained. 

Tympanites. — Troublesome tympanites is often entirely 
overcome by substituting albumin and water for milk. In other 
cases it may be relieved by the external application of turpentine 
stupes and by the internal administration of some antiseptic 
remedy, such as turpentine, beta-naphthol, beta-naphthol bis- 
muth, creosote, or salol. Enemas of turpentine or of asa- 
fcetida are also efficacious. In certain persistent cases, appar- 
ently paretic in nature, the author has successfully employed 
eserin salicylate in doses of ■£$—■£$ gr. (p.ooi-O.0016 gm.) two 
or three times daily, as recommended by von Noorden. Fin- 
ally, when the tympanites is extreme and other measures have 
failed to afford relief, a soft rectal tube may be introduced as 
far as possible into the colon. 

Persistent Vomiting. — When the stomach is excessively 
irritable, it is better to withhold milk for a time and to give 
in its stead albumin and water in small quantities at 
frequent intervals. Occasionally it may be necessary to 
withhold all food by the mouth for twenty-four hours and to 
support the patient by rectal alimentation. The best gastric 
sedative in such cases is bismuth subnitrate in powder, with 
cerium oxalate or cocain hydrochlorid, or in water with dilute 
hydrocyanic acid. A mustard-plaster to the epigastrium is 
often efficacious. 

Hemorrhage from the Bowels. — The patient must be 
kept at absolute rest. Cold bathing must be suspended. If 
the hemorrhage is severe, the bowel-movements should be 
received in a folded towel instead of in a bed-pan. An ice-bag 
may be applied with advantage to the right iliac region, and 
ice may be given by the mouth. It is advisable slightly to 
elevate the foot of the bed. For ten or twelve hours the ali- 
ment should be reduced to the smallest possible amount. The 
best drug is opium ; it controls peristalsis and allays excite- 
ment. Oil of turpentine, in doses of from 10-20 min. (0.6-1.2 c.c.) 



ACUTE INFECTIOUS DISEASES. 513 

every two hours, is also efficacious. Some writers speak favor- 
ably of oil of erigeron. Preparations of ergot are of no value. 
In cases of recurrent hemorrhage gelatin (see p. 381), subcu- 
taneously or by the bowel, should be tried. Rectal injections 
both of iced water and of very hot water (no° F. — 43. 5 C.) 
have been recommended. If collapse is threatened, diffusible 
stimulants, like ether and alcohol, should be given freely. 
The acute anemia following copious bleeding is best treated by 
subcutaneous or intravenous injections of warm saline solu- 
tions (see p. 496). 

Headache. — In most cases absolute rest, quiet, and cold 
applications to the -head suffice. If the pain is severe, it may 
be necessary to give sodium or potassium bromid (10-15 gr. — 
0.65-1.0 gm.) or small doses (5 gr. — 0.3 gm.) of phenacetin. 

Insomnia. — Opium is generally the best hypnotic. In 
some cases, however, sodium bromid or chloralamid acts 
better. Chloral is also very efficacious, but it should not be 
used when the heart is weak. 

Delirium is best managed by hydrotherapy. Low, mut- 
tering delirium usually calls for stimulants. An ice-cap is 
useful. Camphor or musk may be tried ; the former is best 
given hypodermically, the latter by the bowel. In active or 
violent delirium no drug is so generally useful as morphin. 
In some cases hyoscin ( 1 | - 1 ^ gr. — 0.00043-0.00064 gm.) 
acts well. 

Hypostatic Congestion of the I,ungs. — Frequent 
change of position and the timely use of cardiac stimulants 
will frequently prevent serious pulmonary congestion. When 
severe enough to embarrass the respiration and circulation, 
dry cups or stupes should be applied to the chest, and strych- 
nin or ammonium carbonate given internally. In grave cases 
oxygen inhalations afford relief, but their effects are usually 
temporary. 

Perforation. — Recovery from peritonitis is so exceedingly 
rare under medicinal treatment that operative interference is 
called for in all cases which are not obviously moribund. The 
operation should be done at the earliest possible moment. 
Mauger reports 25 recoveries in 107 cases, and Harte and 
Ashhurst 362 cases with 94 recoveries. From these statistics 
operation appears to save life in from 20 to 25 per cent, of the 
cases. 

Bed-sores. — This complication can usually be prevented 
by absolute cleanliness, frequent change of position, the appli- 
33 



514 



APPLIED THERAPEUTICS. 



cation of whisky or whisky and alum to parts most sub- 
jected to pressure, and the timely use of a water-bed or of 
air-cushions. Slight abrasions may be painted with flexible 
collodion or dusted with a powder of bismuth subnitrate and 
iodoform or of boric acid and starch. When there is great 
difficulty in keeping the parts dry, zinc ointment may be freely 
applied. Ulcers should be washed with weak antiseptic lotions, 
dusted with some antiseptic powder like iodoform or iodol, and 
then protected by a large piece of soap-plaster. An ointment 
of balsam of Peru (i : 30) is sometimes very efficacious. 

TYPHUS FEVER. 

As typhus fever is a contagious disease, the patient must be 
isolated and every precaution must be taken to prevent the 
dissemination of the morbific agent, whatever it may be. 
Those who have had experience in typhus epidemics assert 
that free ventilation is often in itself sufficient to arrest the 
transmission of the disease. There is no specific treatment. 
The diet should be nutritious and easily assimilable. As in 
other continued fevers, liquids are better borne than solids, 
although special precautions are not so imperatively demanded 
as they are in typhoid fever. The pyrexia, nervous phenomena, 
heart-failure, and pulmonary congestion will require the same 
treatment as in typhoid fever. 

RELAPSING FEVER. 

As in all contagious diseases, isolation, free ventilation, and 
disinfection of excreta and clothing are important safeguards 
against the spread of the virus. The treatment is purely 
symptomatic. Absolute rest, good nursing, and proper diet 
will do much to avert complications. The chief indications are 
to control the fever, to quiet the stomach, to relieve the intense 
pains in the head, back, and limbs, and to support the heart. 

On account of the short duration of the febrile paroxysms 
the fever itself is not so important a factor as it is in many 
other acute infections. Ordinarily, the application of ice to 
the head, with frequent cold sponging of the body, will suffice. 
Cold baths are not well borne on account of the severe mus- 
cular pains. Hyperpyrexia must be controlled by the cold 
pack and the administration of phenacetin or antipyrin or of 
large doses of quinin. 

Vomiting is sometimes exceedingly difficult to control. 
Cracked ice, carbonated water, dilute hydrocyanic acid (1-2 
min. — 0.06-0.1 ex.), cocain hydrochlorate (J gr. — 0.016 gm.), 



ACUTE INFECTIOUS DISEASES. 5 15 

or wine of ipecac (i min. — 0.06 c.c.) should be tried. A mus- 
tard-plaster to the epigastrium is sometimes efficacious. 

For the relief of the pains, restlessness, and insomnia no drug 
is so useful as morphin. A quarter of a grain (0.016 gm.) 
may be given hypodermically two or three times a day. Hot- 
water bags may also be ordered for the backache, and rube- 
facient liniments for the muscular pains. Stimulants are not 
generally required, but when there is any tendency to heart- 
failure they should be administered freely. 

CEREBROSPINAL FEVER. 

Cerebrospinal fever being communicable, the same precau- 
tions should be observed as in the case of other serious con- 
tagious diseases. The sick-room should be quiet, darkened, 
and well ventilated. The diet should be liquid and support- 
ing. Milk and animal broths may be given freely at fre- 
quent intervals. In some cases, in order to secure the inges- 
tion of enough nourishment, it may be necessary to resort to 
nutrient enemata or forced feeding by means of a stomach- 
tube. Cardiac failure must be combated by stimulants, of 
which the best are whisky and brandy. 

The number of patients treated with the antiserum prepared 
by Flexner (see p. 434) is still too small to justify a positive 
opinion concerning its exact value and limitations ; neverthe- 
less, the reports to date are sufficiently favorable to warrant a 
thorough trial of the remedy in all cases, even of suspected 
meningococcic meningitis. 

Morphin hypodermically is the best drug for the relief of 
headache, pain, and restlessness. Chloral, bromids, and 
phenacetin in safe doses are rarely effective. Cold applied to 
the head affords some relief. Warm baths (105 °-i io° F.) twice 
a day for ten minutes are often very efficacious. 

When there are evidences of excessive intraventricular pres- 
sure (intense headache, retraction of the head, convulsions, 
and stupor), the withdrawal of from 30 to 40 c.c. of fluid from 
the spinal canal sometimes has a happy effect. 

After the subsidence of the acute symptoms the absorption 
of the exudation may be attempted by the administration of 
potassium iodid. When symptoms indicating pressure on the 
brain or spinal cord persist, repeated blisters or light applica- 
tions of thermocautery are sometimes useful. Tonics — iron, 
strychnin, cod-liver oil — are generally indicated during con- 
valescence. Local palsies will require massage and electricity. 



5 l6 APPLIED THERAPEUTICS. 

Even after convalescence has been well established all mental 
and physical excitement should be avoided for a considerable 
period. 

MALARIAL FEVER. 

It has been definitely established that the hemocytozoan 
discovered by Laveran in 1880 is the sole cause of malarial 
fever, and that the mosquito plays an important role in trans- 
mitting the infection. Prophylactic measures include the ex- 
termination of mosquitos, the prevention of infection of mos- 
quitos, and the prevention of infection by mosquitos (Manson). 
The most useful methods of suppressing mosquitos are the 
efficient drainage of pools and swamps and the cultivation of 
damp soils. Covering the surface of the water with petroleum 
will also free pools from larvas for from two to four weeks. To 
prevent the infection of mosquitos, malarial patients should be 
carefully screened. The chief means of preventing infection 
by mosquitos are avoidance of sleeping in the open air, and 
of exposure to the evening and early morning air, adequate 
protection from the insects, and the use of quinin in daily 
doses of from 2-5 gr. (0.13-0.3 gm.). 

Quinin is the only reliable remedy for malarial fever. 
Methylene-blue and Warburg's tincture possess some value, 
but, being distinctly less efficacious than quinin, they should 
be employed only when the latter is not well borne. Arsenic 
is useful in correcting the anemia caused by malarial fever, but 
it probably has no parasiticidal influence. The methods of 
administering quinin and other antimalarial remedies has 
already been considered (see p. 414). 

Symptomatic Treatment. — During the cold stage of the par- 
oxysms the patient should be well covered with warm blankets 
and given hot drinks. Opium in the form of paregoric is 
sometimes useful in mitigating discomfort. It may be com- 
bined with a few minims of aromatic spirits of ammonia, 
chloroform, or Hoffmann's anodyne. Generally, alcoholic 
stimulants are better avoided, since they tend to increase the 
severity of the reaction. In the algid type of pernicious 
malarial fever, however, it may be necessary to give alcohol 
freely, with digitalis and strychnin, to tide the patient over the 
paroxysm. In the hot stage much relief is afforded by fre- 
quently sponging the body with cool water, giving cold drinks, 
and administering, if the symptoms are very severe, a small 
dose of phenacetin. 

When the bowels are constipated and the tongue is thickly 
coated, laxative doses of calomel or of blue-mass may be given 
with advantage. Vomiting and purging are occasional symp- 
toms ; they are best controlled by an opiate. 



ACUTE INFECTIOUS DISEASES. $iy 

In the graver congestive type, with coma and high fever, 
cold bathing and rectal injections of cool water are indicated. 

For the anemia following malarial infection arsenic and iron 
should be given (see p. 311). 

Malarial cachexia requires tonic and hygienic treatment. 
Arsenic, iron, and cod-liver oil are especially valuable. As in 
other manifestations of malaria, quinin is indicated so long as 
the blood shows parasites. According to Wood, it is much 
better to produce distinct cinchonism at intervals than to give 
the drug continuously in moderate doses. When there is 
constipation, mild bitter laxatives are beneficial. Change of 
locality is sometimes necessary to effect a cure. For the en- 
larged spleen, ergot has been warmly advocated, but it is of 
doubtful utility. 

INFLUENZA* 

Although we possess no certain safeguards against the 
spread of influenza, yet an effort should always be made to 
protect healthy members of the household, especially the 
young, old, and delicate, from infection. To this end the 
patient should be isolated, and the secretion from the catar- 
rhal surfaces should be thoroughly disinfected. 

No specific has yet been discovered for the disease. Hy- 
gienic measures are of the first importance ; these include im- 
mediate and absolute rest in bed, a carefully selected diet, pure 
air without draft, and attentive nursing. Complications and 
relapses can generally be traced to a neglect of these rules. 

In mild cases little in the way of special treatment is re- 
quired. A hot foot-bath, some mild refrigerant, such as spirit 
of nitrous ether or solution of ammonium acetate, and at night 
a dose of Dover's powder (5-10 gr. — 0.3-0.6 gm.), will usually 
suffice. If there be constipation, a few minute doses of calomel 
may be given with advantage; active purgation, however, 
should always be avoided. 

In the more severe cases quinin, if well borne, may be given 
in small doses (2-5 gr. — 0.13-0.3 gm. — thrice daily) throughout 
the attack. Rheumatoid pains are controlled to some extent 
by combinations of phenacetin with salicylates or benzoates. 
Only small doses, however, are admissible, and these should 
be carefully watched. The following is often useful : 

R Acetphenetidini, 

Salophen, 

Sodii benzoatis, aa £j (4.0 gm.). M. 

Fiant chartulae No. xii. 
Sig. — One every four hours. 



5 l8 APPLIED THERAPEUTICS. 

When the suffering is intense, there need be no hesitation 
in administering morphin hypodermically. Violent headache 
is treated best by small doses of phenacetin and the applica- 
tion of an ice-cap to the head. Sulphonal and chloralamid are, 
perhaps, the most satisfactory drugs for combating trouble- 
some insomnia. When the stomach is persistently irritable, 
the diet should be restricted to liquids, and all drugs, except 
those of a soothing character, withheld. Antiemetics, like 
bismuth subnitrate, hydrocyanic acid, cerium oxalate, and 
cocain, are indicated. A sinapism to the epigastrium may also 
be recommended. 

In many cases of influenza cardiac weakness is a prominent 
feature. It demands the free use of alcoholic stimulants and 
of strychnin. The latter is especially well borne, and may be 
given, if necessary, in doses of ^o~ 2V °f a S r - (0.002-0.003 gm.) 
every three or four hours. If more stimulation is required, 
aromatic spirits of ammonia and digitalis or strophanthus may 
also be given. 

As the course of the disease is comparatively short, the 
fever, even when high, will rarely call for special medica- 
tion. Antipyretic drugs in large doses are always inad- 
missible. Delirium is another symptom that may usually be 
ignored. 

In the respiratory type expectorants are usually needed. 
When the cough is hard and dry, combinations of ipecac and 
potassium citrate, like the following, will be found useful : 

R Potassii citratis, £ij (8.0 gm.) ; 

Syrupi ipecacuanhse, 

Tincturae opii camphoratae, aa fjij (8.0 c.c.) ; 

Succi limonis, 

Glycerini, aa fjss (15.0 c.c); 

Aquae, q. s. ad fijjiij (90.0 c.c). M. 

Sig. — A dessertspoonful every two or three hours. 

When expectoration is established, expectorants like ammo- 
nium chlorid, squills, and terpin hydrate may be substituted 
for ipecac and potassium citrate. Stupes or sinapisms to the 
chest are also useful in relieving cough. When pneumonia is 
threatened, dry cupping is often efficacious. 

The convalescence should be most carefully watched, and 
strict injunctions given as to diet, rest, and the avoidance of 
exposure. Tonics are usually indicated and may be continued 
for several weeks. Change of air will materially help to restore 
strength and to overcome the peculiar mental depression. 



ACUTE INFECTIOUS DISEASES. 519 

CROUPOUS PNEUMONIA. 

Prophylaxis against croupous pneumonia consists largely in 
the avoidance of influences which tend to lower the resistance 
of the tissues. Undue exposure to cold and the excessive use 
of alcohol are important predisposing factors. Persons who 
have had one attack of pneumonia should be particularly at- 
tentive to their personal hygiene. 

The sick-room should be well ventilated, but free from 
drafts. Indeed, the open-air treatment, as applied to tubercu- 
losis, cannot be too strongly recommended. Fresh, pure air 
may be secured by screening off the bed and a portion of the 
room next to a window. This method of treatment may be 
adopted without regard to seasons or atmospheric conditions. 
The patient's sputum and all articles liable to be soiled with 
the sputum should be disinfected. 

The diet should be fluid or semifluid. Milk, junket, wine- 
whey, broths, eggs, and gruel are suitable forms of nourish- 
ment. Cool water should be given freely. 

Specific Treatment. — Croupous pneumonia cannot be 
aborted. Many methods of specific treatment have been 
recommended, but none has proved satisfactory. From the 
time of Laennec down to about the middle of the last cen- 
tury venesection was thought to be imperative. To-day, it is 
rarely practised except to meet certain indications. 

In robust subjects, at the very onset, when the invasion is 
violent and attended with high fever, a bounding pulse, marked 
dyspnea, and severe pleuritic pain, the abstraction of from 
10-20 oz. (300.O-600.0 c.c.) of blood may afford great relief. 
Later in the course of the disease, if cyanosis and orthopnea 
develop in consequence of overdistention of the right ventricle, 
venesection may also prove useful. 

Tartar emetic, which at one time was thought to possess 
the power of aborting croupous pneumonia, has been entirely 
abandoned. The same fate has almost overtaken veratrum 
viride, although some clinicians still recommend it as a sub- 
stitute for venesection. 

The treatment of pneumonia by large doses of digitalis, — 
1-2 oz. (30.0-60.0 c.c.) of the tincture daily, — originally pro- 
posed by Petresco of Bucharest, has never had many advo- 
cates in this country. In 1894 Petresco reported 1192 cases 
treated by this method, with a mortality of 2.66 per cent. But 
the author himself states that the treatment is not applicable 
to very grave cases, and that his observations were made in a 
military hospital on young and robust men. Petresco's fig- 



520 APPLIED THERAPEUTICS. 

ures lose much of their significance when we compare them 
with the death-rate in the German army, which, according to 
Osier, was only 3.6 per cent, in 40,000 cases of pneumonia 
among healthy picked men. 

Aufrecht ardently advocates the hypodermic administration 
of quinin, — 8 gr. (0.5 gm.) once or twice a day, — not as an 
antipyretic, but as a specific, remedy. The mortality under 
this treatment in a series of 261 patients treated in the Altstadt 
Hospital at Magdeburg was 8.8 per cent., but we learn from 
Strusberg that in the medical clinic at Bonn during the same 
period the mortality under symptomatic treatment was only 
7.97 per cent. 

Carbonate of creosote (2-3 fl. dr. — 8.0-1 1. o c.c. daily) has 
recently been highly extolled as a specific by Van Zandt, 
Weber, and others. In the author's experience this drug has 
not hastened the crisis nor exerted any appreciable influence 
on the general toxemia. 

Of all the special remedies recommended for pneumonia, 
antipneumococcic serum was the most promising. Perhaps 
sufficient time has not yet elapsed to warrant a final opinion 
upon its efficacy, but certainly those who have given it a fair 
trial will admit that it has fallen considerably below their ex- 
pectations and has yielded results in no way comparable to 
those obtained in diphtheria from the use of antitoxin. In a 
fair test made by J. C. Wilson in the German Hospital, Phila- 
delphia, the mortality under serum treatment in one series of 
18 cases was 22.2 per cent., and in another series of 18 cases, 
35.3 per cent. 

Although we have yet no specific treatment, much may be 
done in the way of symptomatic treatment to avert a fatal 
issue." The indications, however, are extremely variable and 
must be carefully considered in each case. Routine treatment 
is to be rigidly avoided. In a large number of cases no drugs 
are needed. The symptoms that most often demand special 
attention are the pain, cardiac weakness, cough, fever, dyspnea, 
insomnia, and delirium. 

Pain. — Morphin hypodermically is the best drug for sub- 
duing pleuritic pain. It also serves to overcome the restless- 
ness and anxiety which often mark the onset of the disease, 
and which, if allowed to continue, tend to augment the ex- 
haustion. Hot or cold applications to the chest are also use- 
ful. When the suffering is very severe, a few wet or dry cups 
to the affected side, followed by poultices, will be found effica- 
cious. 



ACUTE INFECTIOUS DISEASES. 52 1 

Cardiac Weakness. — Alcohol is the best stimulant. When 
the pulse becomes compressible and dicrotic, and the diastolic 
sound at the pulmonary area loses its force, it should be given 
freely. Often 3 or 4 ounces (90.0-1 18.0 c.c.) of good whisky 
in the twenty-four hours will suffice, but in some instances two 
or three times this amount may be given with advantage. The 
patients who need it most are the old, the debilitated, and the 
alcoholic. Digitalis is undoubtedly useful in some cases, but 
its action is uncertain and often disappointing. In the author's 
experience it has been almost invariably badly borne when 
administered for the irregular flagging pulse of the period im- 
mediately following the crisis. Its frequent failure at other 
times maybe explained by the fact that the cardiac insufficiency 
in the majority of cases is not dependent on simple dilatation 
or relaxation of the ventricles, but on degenerative changes in 
the myocardium, or perhaps, in some instances, on disturbances 
of the motor ganglia of the heart, brought about by the infection. 
Mechanical distention of the right ventricle undoubtedly does 
occur in some cases. It may be recognized by the enlarge- 
ment of the area of cardiac dulness, by the marked cyanosis, 
the orthopnea, and the small pulse. In this condition digitalis, 
by driving the blood with great force against an impassable 
barrier, is likely to do harm ; it is better to relieve the strain 
on the right ventricle by judicious venesection. 

As a circulatory stimulant, strychnin generally proves much 
more efficacious than digitalis. It should be given in ascend- 
ing doses of from q - ^ of a gr. (0.001-0.0043 gm.), careful 
watch being kept for the appearance of untoward symptoms. 
In order that there may be immediate absorption, large doses 
should always be given hypodermically. Caffein is a useful 
adjuvant to stiychnin, but it should not be used when there is 
cerebral excitement or insomnia. Wood speaks well of cocain 
— E~i S r - (0.01-0.03 gm.) — alternately with strychnin, one or 
the other being given in grave cases every two hours. In 
threatening collapse the author has found no stimulant so 
generally serviceable as camphor. It is especially useful in 
tiding the patient over the profound depression that often 
accompanies or follows the crisis. It is available also when 
pulmonary edema arises as a complication, and in this con- 
dition it may be advantageously combined with atropin. To 
secure the best results, camphor should be given hypoder- 
mically, dissolved in ether or sterile olive oil, in doses of from 
1-2 gr. (0.06-0.13 gm.) every two or three hours. 

Subcutaneous injections of normal salt solution have also 
been useful in overcoming adynamia. 



522 APPLIED THERAPEUTICS. 

Cough. — For the hard, dry cough, especially of the first 
stage, no remedy is so useful as opium in the form of Dover's 
powder. Expectorants are rarely needed. The inflammatory 
exudation in the air-vesicles is removed almost entirely by 
absorption, and to attempt its expulsion by means of a drug 
is useless. When, however, there is a good deal of bronchial 
catarrh, with much viscid sputum, ammonium carbonate may 
be given to facilitate expectoration, but it should be withdrawn 
immediately if it causes any disturbance of digestion. 

Fever. — The fact that in a very large proportion of the 
gravest cases the temperature is not high indicates that the 
chief factor in bringing about the exhaustion is not the fever 
itself, but the toxemia. This being the case, and as the febrile 
period is generally of a comparatively short duration, anti- 
pyretic measures may be restricted in the majority of cases to 
frequent cold sponging and the application of an ice-bag or an 
ice-poultice to the affected side. 

Persistent high temperature is best controlled by cool baths 
(8o° F. — 27.5°C). Experience is strongly against the syste- 
matic employment of antipyretic drugs, like phenacetin and 
antipyrin. 

Dyspnea. — Cardiac stimulants, since they favorably in- 
fluence the pulmonary circulation, are also of service in re- 
lieving dyspnea. Naturally, the circulatory stimulants that 
are also respiratory stimulants, like strychnin, caffein, and 
cocain, are the most useful. Oxygen makes the breathing 
easier, lessens cyanosis, and conduces to sleep, and to this 
extent aids in conserving energy. 

Insomnia and Delirium. — When insomnia and delirium 
are sufficiently severe to demand the use of drugs, morphin 
will generally be found the most efficacious. Of course, it 
should not be used when there is extreme dyspnea or when 
there are evidences of pulmonary edema. When the circula- 
tory depression is not marked, chloral may be used. In other 
cases, chloralamid or sulphonal may be tried. 

Delayed resolution is a troublesome complication. For- 
tunately, it is of rare occurrence. It sometimes yields to 
repeated blistering and the free use of tonics. Riess has 
recommended injections of pilocarpin, and Dieulafoy, Forbier, 
and Lepine the production of aseptic abscesses by means of 
turpentine injections. Edsall and Pemberton have recently 
reported three cases in which rapid improvement occurred 
under the use of ;r-rays. 



ACUTE INFECTIOUS DISEASES. $2$ 

DIPHTHERIA, 

Diphtheria being a highly contagious disease, the utmost 
care should be taken to prevent the spread of the specific virus. 
General prophylactic measures include the isolation of the sick, 
absolute cleanliness in the sick-room, and the thorough disin- 
fection of all articles of clothing and fomites that may have 
become contaminated with the secretions from the infected 
area. As diphtheria bacilli often remain in the throat for weeks 
or even months after the disappearance of the false membrane, 
isolation should be urged until the bacilli can no longer be 
detected in the throat by bacteriologic examination. 

Physicians and nurses, in applying local remedies, must be 
exceedingly careful lest they become infected directly by shreds 
of false membrane expelled by the patient in coughing. 

Finally, exposed persons, especially children, should receive 
an immunizing dose of diphtheria antitoxin (see p. 431). 

The sick-room should be well ventilated, and the tempera- 
ture maintained at about Jo° F. (21 C). It is desirable to 
have the atmosphere moist, and this may be accomplished by 
generating steam in an ordinary kettle or in a steam atomizer, 
or by slaking large quantities of quicklime in the room. Young 
children, especially when laryngeal symptoms are present, are 
best treated in a steam-moistened tent. Absolute rest must 
be enforced. The diet should be of the most nutritious and 
easily digested character. Milk, junket, ice-cream, eggs, and 
unseasoned broths may be allowed. After tracheotomy it may 
be necessary, in order to introduce sufficient nourishment, to 
feed through a soft-rubber nasal tube. Cool water should be 
given freely. The medicinal treatment of diphtheria is both 
local and constitutional. 

I/OCal Treatment. — Local treatment is of great importance, 
but often difficult to carry out. When the applications cause 
violent struggling and exhaust the child, it may be better to 
desist. Applications should be made with utmost gentleness, 
should be unirritating, and should be frequently repeated. 
Remedies may be applied by means of absorbent cotton on a 
swab, or by sprays, injections, or irrigations. In pharyngeal 
diphtheria the first method is usually the best, while in nasal 
diphtheria the employment of a syringe or irrigator is prefer- 
able. The nozzle of the instrument should be blunt and cov- 
ered with soft rubber, and the nurse should be instructed to 
introduce it gently and in a horizontal direction. In both nasal 
and pharyngeal diphtheria, when the child cannot be raised, 
the fluid may be poured into the nose from a spoon, minim- 
dropper, or, better, from a nasal cup (Jacobi). Sprays are not 



524 APPLIED THERAPEUTICS. 

very efficacious. In laryngeal diphtheria local treatment is 
rarely feasible, except by means of medicated vapors. 

Many local remedies have been recommended ; the following 
are, perhaps, the most generally useful : Solution of hydrogen 
dioxid (1:2 of lime-water), Loffler's solution (see p. 293), or 
corrosive sublimate (1 : 5000 to 1 : 1000). All applications to 
the nasal mucous membrane should be warm. False mem- 
brane should never be torn off, but when it is very loose, it 
may be carefully dislodged and removed. Emetics are some- 
times useful in expelling false membrane from the larynx, but 
when there are marked symptoms of obstructive dyspnea, the 
operation of intubation or tracheotomy should not be deferred. 

Externally, hot or cold applications, whichever may be more 
grateful to the patient, are useful in relieving pain and soreness 
in the throat. When there is marked swelling of the cervical 
glands, an ointment of mercury and belladonna is sometimes 
of service. 

Constitutional Treatment. — Statistical reports from all 
parts of the world prove conclusively that the remedy of 
greatest value in the treatment of diphtheria is the blood- 
serum of animals rendered artificially immune against the dis- 
ease (see article on Diphtheria Antitoxin, p. 431). Apart 
from antitoxin, the most important remedies are those which 
tend to maintain the bodily strength. Alcoholic stimulants 
are usually indicated, especially in the late stage of the disease. 
In septic cases alcohol is particularly well borne, a child of 
three years often being able to take several ounces of whisky 
a day with advantage. Next to alcohol, strychnin is the best 
stimulant. In profound adynamia, digitalis, caffein, camphor, 
and musk are also useful. 

Two drugs which are believed to be of special value, but 
which have lost some of their reputation since the introduc- 
tion of antitoxin, are the tincture of the chlorid of iron and 
mercury. From 3-5 min. (0.2-0.3 c.c.)of the tincture of ferric 
chlorid may be given in glycerin or water every two or three 
hours to a child of four years. It should, however, be sus- 
pended on the first appearance of digestive disturbance. 
Children with diphtheria are usually very tolerant of mercury, 
and as much as -fa of a grain (0.0016 gm.) of corrosive sub- 
limate may be given every three hours to a child of three or 
four years. 

Potassium chlorate is another popular remedy. Its action, 
however, is a purely local one. On account of its irritant 
effects on the kidneys it should never be used internally. 
Convalescence must be managed with special care, on account 



ACUTE INFECTIOUS DISEASES. $2$ 

of the tendency to cardiac weakness. Anemia, a common sequel, 
■will require good hygienic surroundings, plenty of nourishing 
food, and iron. Diphtheric paralysis usually yields to strych- 
nin and other tonics, combined with the use of massage and 
electricity. 

SCARLET FEVER. 

To prevent the spread of the disease, the patient should be 
rigidly isolated. The sick-room should be large and airy, and, 
if possible, it should be at the top of the house. All unneces- 
sary furniture should be removed from the room, and no one 
should be allowed to enter it except the physician and nurse. 
The nurse should wear a loose wrapper and cap, to be left 
inside the room when she is obliged to leave it. All articles 
that have been in contact with the patient should be thoroughly 
disinfected before they are permitted to be taken from the 
room. Finally, to prevent the dissemination of the scales, 
some bland ointment (cold cream, olive oil, cocoa-butter) 
should be applied to the patient's body at least once a day 
until desquamation is complete. During the period of active 
desquamation the inunctions should be preceded by warm 
alkaline baths. 

The treatment of scarlet fever is purely symptomatic. The 
patient should be kept in bed until the end of desquamation. 
The diet should consist of milk, junket, koumiss, ice-cream, 
fruit-juices, and gruels. So as not unnecessarily to tax the 
kidneys, animal broths and meat should be withheld, if pos- 
sible, until convalescence is well established. Water should 
be given freely to relieve thirst and to keep the secretions 
active. 

In many cases no special medication is required beyond the 
use of a mild refrigerant mixture, such as the following : 

R Spiritus aetheris nitrosi, fzvj (22.5 c.c.) ; 

Liquor ammonii acetatis, q. s. ad fgiij (90.0 c.c). M. 
Sig. — Dessertspoonful with water every three hours for a child of 
five years. 

Vomiting. — When vomiting is severe, it may be necessary 
to withhold food for several hours and to administer an anti- 
emetic, such as ice, carbonated water, bismuth subnitrate with 
hydrocyanic acid, or cocain ( 2 1 o ~ i 1 q S r - — O.003-0.006 gm.). In 
very obstinate vomiting opium suppositories or chloral enemata 
should be tried. 

Fever. — Tepid sponging is very grateful throughout the 
febrile period. Fever above 103 F. (39.5 ° C.) should be com- 
bated with cold packs or gradually cooled baths (8o° F. — 



526 APPLIED THERAPEUTICS. 

26. 5 C), and by cold applications to the head. Phenacetin, 
antipyrin, and other antipyretic drugs should not be used 
except as a last resort, and then only in small doses. 

Cardiac Weakness. — If the heart shows signs of failing, 
alcoholic stimulants will be demanded. Many practitioners 
believe that the tincture of ferric chlorid (1 drop a dose for 
each year of the child's age) exerts a favorite influence upon 
the general toxemia. Threatened collapse will require the use 
of such remedies as strychnin, digitalis, camphor, ammonia, 
and musk. 

Nervous Symptoms. — Restlessness, jactitation, head- 
ache, and insomnia will generally yield to small doses of a 
bromid and to the application of cold to the head. When 
these symptoms are severe, however, no remedy is so useful 
as chloral. It may be given in doses of from 3-5 grains 
(0.2-0.3 gm.) every three or four hours. Nervous symptoms 
the result of high fever will, of course, require vigorous anti- 
pyretic treatment. 

Throat Symptoms. — Cleansing of the nose and throat 
with mild antiseptic sprays or washes will do much to prevent 
the development of septic adenitis and middle-ear disease. 
Weak DobelPs solution or solution of hydrogen dioxid (1:3) 
may be used for this purpose. When tonsillitis is severe, the 
following application will be found useful : 

R Potassii chloratis, gr. xx (1.3 gm.) ; 

Tincturse ferri chloridi, 

Glycerini, aa f^ss (15.0 c.c.) ; 

Aquae, q. s. ad fljij (60.0 c.c). M. 

Sig. — Apply to the tonsils several times a day with a cotton swab. 

Pain and swelling in the neck are best relieved by ice poul- 
tices ; in some cases, however, hot compresses are more grate- 
ful. When suppuration occurs, the abscess should be freely 
opened and dressed antiseptically. 

In acute Otitis media nothing affords so much relief as 
gently syringing the auditory canal with hot water. The 
application of a leech behind the ear is also useful. When 
the tympanic membrane bulges, indicating the presence of 
pent-up pus, the latter should be evacuated by puncture. 

Nephritis. — A milk diet, tepid bathing during the febrile 
period, and the avoidance of exposure for several weeks after 
the subsidence of the fever are important prophylactic meas- 
ures against nephritis. Should this complication develop, 
however, dry cupping over the loins, followed by warm fomen- 
tations, will often prove of value. Aperients, especially salines, 



ACUTE INFECTIOUS DISEASES. $2? 

are indicated. Warm baths, hot packs, vapor baths, or pilo- 
carpi ( jV ' r o S r - — 0.004-0.006 gm.) should be used to pro- 
mote diaphoresis. When the urine is scanty, unirritating diu- 
retics, like potassium acetate or bitartrate and digitalis, are of 
service. 

MEASLES AND RUBELLA. 

The prophylactic measures described in connection with 
scarlatina are applicable in measles and rubella. 

Measles is a self-limited disease and cannot be aborted. 
The temperature of the sick-room should be maintained at 
about 68° F. (20 C). The patient should be kept in bed 
until all traces of the rash ha\e disappeared, and confined to 
his room for a week or ten days longer. On account of the 
photophobia the room should be moderately darkened, and 
the bed so arranged that the face will be directed away from 
the light. When the cough is troublesome, the atmosphere 
should be kept moist. 

Milk, junket, fruit-juices, broths, eggs, and gruels are suita- 
ble forms of nourishment. Water should be proffered at fre- 
quent intervals. Stimulants are rarely required except in 
malignant cases. 

Daily inunctions of the body with cold cream or olive oil 
will serve to allay burning and itching of the skin. Spraying 
the nose and throat at frequent intervals with warm Dobell's 
solution will aid in preventing buccal and aural complications. 
When conjunctivitis is marked, the eyes should be protected 
with dark glasses and frequently cleansed with a solution of 
boric acid (15 gr. to the oz. — 1.0 gm. to 30.0 c.c). Hot baths 
and hot drinks are indicated when the rash is delayed. 

Fever, unless persistently high, may be left alone. When 
antipyretic measures are required, tepid sponging or immer- 
sion for a few minutes in water gradually cooled from 95 ° F. 
(35 C.) to 8o° F. (26.5 C.) will be found the most satisfactory. 
Antipyretic drugs should be used only as a last resort. 

The medicinal treatment of measles is usually very 
simple. Constipation should be relieved by small doses of 
calomel or by glycerin suppositories. Severe vomiting may 
require cracked ice, lime-water, bismuth subnitrate, cocain, or 
suppositories of opium. Diarrhea will generally yield to a 
few doses of bismuth subnitrate and opium. Troublesome 
headache and insomnia are best treated by bromids or small 
doses of chloral. 

Cough very frequently requires attention. The application 
of sinapisms to the chest, the inhalation of steam, and the 



528 APPLIED THERAPEUTICS. 

administration of sedative expectorants with opium are meas- 
ures calculated to afford relief. The following mixture will be 
found useful : 

R Potassii citratis, gij (8.0 gm.) ; 

Vini ipecacuanhas, fgij (8.0 c.c.) ; 

Tincturae opii camphoratse, fgiij (11.0 c.c); 

Syrupi tolutani, fifj (30.0 c.c.) ; 

Aquae cinnamomi, q. s. ad fgiij (90.0 c.c). M. 

Sig. — A teaspoonful every three or four hours. 

A mixture of ammonium chlorid and syrup of squill will be 
efficacious when the cough loosens. 

The treatment of rubella does not differ materially from 
that of measles. 

SMALLPOX. 

The preventive measures against smallpox include the com- 
plete isolation of the patient (preferably in a special hospital), 
the thorough disinfection of all objects that have been in con- 
tact with him, and, above all, the vaccination of all who have 
been or who are likely to be exposed to the contagion. 

Vaccination. — Vaccination does not afford complete and 
permanent immunity against smallpox, but in the vast majority 
of cases it renders the person insusceptible to the disease for a 
number of years. In Prussia the death-rate from smallpox 
per 100,000 of population prior to the enforcement of general 
vaccination (1846-74) was 24.4, while after the enforcement 
of general vaccination (1874-86) it was only 1.5 (Abbott). 
In the hospitals of London, from 1876-79, there were admitted 
11,412 smallpox patients who had been vaccinated in infancy, 
but not a single case was known to have occurred in a person 
who had been successfully revaccinated (Welch). 

Vaccination should be performed at the third month (earlier 
if smallpox be epidemic), again at puberty, and subsequently 
whenever smallpox is prevalent. Only bovine lymph should 
be used, and preference should be given to that which has 
been glycerinated and preserved in hermetically sealed glass 
tubes. The part selected should be thoroughly cleansed, first 
with soap and water, then with alcohol, and finally with pure 
water. Many methods of performing the operation are recom- 
mended. The simplest is to make, with a sterile lancet or 
special scarificator, a number of cross scratches, only deep 
enough to allow of a little oozing of pinkish serum. The with- 
drawal of blood is to be carefully avoided, as it tends to wash 
away the vaccine material. The virus is now applied and well 
rubbed into the exposed lymphatic spaces by additional scan- 



ACUTE INFECTIOUS DISEASES. $ 2 9 

fication. A shield may be worn for a few hours, until the 
wound has become perfectly dry ; after that it should be dis- 
carded, since it serves, especially if tight-fitting, to intensify the 
inflammatory reaction. 

For a vaccination to be considered successful the vaccine 
lesion should pass through a papular, vesicular, and pustular 
stage, and leave behind a permanent cicatrix. A typical vesicle 
resembles " a section of a pearl on a rose leaf" (Jenner). A 
good scar is pale, sharply defined, and pitted. 

General Management. — There is no specific for small- 
pox. Absolute rest in bed, light bed-clothing, a well-ventilated 
room of a temperature of 65 F. (18.5 C), an easily assim- 
ilable but sustaining diet, and the free use of cool drinks 
are requisites of treatment. The severe lumbar pains will 
require opium and the application of hot-water or hot-bran 
bags. Fever above 103 F. (40 C.) is best combated by 
hydrotherapy — cold sponging, cold packs, or cold baths. 
Antipyretic drugs should be used with great caution. 

Gastric irritability may be controlled by dilute hydrocyanic 
acid (2 min. — 0.1 c.c), subnitrate of bismuth (10 gr. — 0.6 gm.), 
or cocain (-|- gr. — 0.008 gm.). Diarrhea should be remedied 
by the use of bismuth and morphin powders (see p. 375). 
When nervous symptoms — jactitation, delirium, and insomnia 
— are not relieved by hydrotherapy, opium with bromids or 
chloral with bromids should be tried. Alcoholic stimulants 
are frequently demanded, especially in confluent cases. Quinin 
is also useful in the adynamia of sepsis. 

An attempt should be made to keep the nasopharynx clean 
by means of antiseptic sprays or douches. For this purpose . 
Dobell's solution or solution of hydrogen dioxid (1:4) will 
be found useful. The eyes should also be kept clean by fre- 
quent applications of a warm boric-acid solution (15 gr. to the 
ounce — 1.0 gm. to 30.0 c.c). 

The Eruption. — Cool antiseptic washes, such as carbolic, 
I : 200, or corrosive sublimate, 1 : 5000-1 : 10,000, are, per- 
haps, the most useful applications that can be made to the skin. 
Compresses wet with these solutions may be kept constantly 
on the face and hands to exclude the light, which, there is 
some reason to believe, acts unfavorably on the pocks. Many 
remedies have been recommended to prevent pitting, but it is 
doubtful whether any are really efficacious. An old plan was 
to open the vesicles and touch their base with a stick of silver 
nitrate. Dujardin-Beaumetz recommended an ointment of 
sodium salicylate (4 parts) and cold cream (100 parts). Hebra 
speaks favorably of continuous warm baths. Finsen, Feilberg, 

34 



530 APPLIED THERAPEUTICS. 

and others recommend the exclusion of the chemical rays of 
light from the sick-room, red light only being admitted ; but 
this plan of treatment does not appear to be particularly bene- 
ficial, and has the drawback of putting a check on the supply 
of fresh air. 

In the stage of desiccation, warm baths followed by inunc- 
tions with cold cream or olive oil are useful in allaying itching 
and in hastening the removal of the crusts. 

YELLOW FEVER. 

In the absence of any specific remedy, the treatment of 
yellow fever must be mainly expectant. Absolute rest and 
quiet, a sick-room well ventilated but free from drafts, and 
careful nursing are essential. The patient should be isolated, 
and protected by nets and wire screens from mosquitoes. Only 
the blandest articles of food should be allowed, and these 
should be given in small quantities. Peptonized milk, milk with 
lime-water, junket, koumiss, milk-punch, barley-water, toast- 
water, and iced champagne are available. Carbonated waters, 
like Vichy and Apollinaris, are grateful and useful. Sternberg, 
Touatre, and many other clinicians of wide experience in the 
treatment of the disease advocate the withholding of all food 
during the first two or three days. 

If the patient be seen in the first twenty-four hours of his 
illness, a hot mustard foot-bath may be given with advantage. 
If there be a tendency toward constipation, a few small doses 
of calomel may be administered and followed by a Seidlitz 
powder, or a purgative enema may be used. 

It is very questionable whether any drug has the power of 
modifying the course of the disease as a whole, although Stern- 
berg is firmly convinced of the efficacy of the following com- 
bination : 

R Sodii bicarbonaiis, £iv (15.0 gm.) ; 

Hydrargyri chloridi corrosivi, gr. ss (0.03 gm.); 
Aquae destillatae, Oj (475.0 c.c). M. 

Sig. — In severe cases, two teaspoonfuls every hour, day and night ; 
in mild cases, every hour by day and every two hours by 
night ; administer ice-cold. 

Obstinate vomiting should be combated by the applica- 
tion of an ice-bag or a sinapism to the epigastrium and by the 
administration of sedatives, like cracked ice, lime-water, hydro- 
cyanic acid, or cocain. In severe cases it is best to let the 
stomach have complete rest and to give morphin hypodermi- 
cally or by the bowel. 



ACUTE INFECTIOUS DISEASES. 53 I 

Systematic cold sponging keeps down the temperature, 
lessens nervous excitability, and favors diuresis. 

High temperature should be controlled by the cold bath. 

Suppression of urine will call for dry cupping over the 
loins, alkaline diuretics, hot-air or hot-water baths, and, perhaps, 
rectal or subcutaneous injections of warm saline solutions (see 
pp. 488-498). 

If there are signs of heart-failure, alcoholic stimulants 
should be given freely : iced champagne and iced brandy with 
soda water are the remedies most favored. Threatened collapse 
will require subcutaneous injections of strychnin, ether, or cam- 
phor, hot baths, and enemata of black coffee or brandy. 

Remedies have little, if any, control over black vomit. 
Guiteras recommends tincture of ferric chlorid, and Carroll, 
oil of turpentine. 

CHOLERA. 

Hygienic measures are of the utmost importance in prevent- 
ing the spread of cholera. Personal prophylactic measures 
against the disease include removal from the infected districts ; 
restriction of the diet to bland, easily digested food; thor- 
ough sterilization of drinking-water and milk ; the protection 
of all food from contamination by flies and other insects ; 
the avoidance of overwork, exposure to wet and cold, and 
undue excitement ; and the prompt treatment of any gastro- 
intestinal disturbance that may arise. Certain acids, especially 
sulphuric acid, have long been advocated as preventives of 
cholera. Finally, vaccination with attenuated cholera cultures, 
as practised by Haffkine in India, has given encouraging 
results. 

Precautionary measures pertaining to the sick comprise iso- 
lation, absolute cleanliness, and the thorough disinfection of 
excreta, soiled clothing, etc. 

The medicinal treatment of cholera resolves itself into that 
of the prodromal stage, that of the algid stage, and that of 
the reaction stage. 

Prodromal Stage. — From the first appearance of diarrhea 
the patient should go to bed and remain there. Food should 
usually be withheld. If there be a history of indigestible food 
having been taken, a laxative dose of calomel or of castor-oil 
should be given ; otherwise, aperients should be avoided. 
Hot stupes maybe applied to the abdomen. If there be much 
colic, morphin may be given hypodermically. In the last 
European epidemic (1892) many good observers reported 
adversely upon the use of opium by the mouth. For the 
diarrhea, bismuth subnitrate is perhaps the best astringent. 



532 APPLIED THERAPEUTICS. 

Algid Stage. — Intravenous injections of warm saline solu- 
tions (see p. 496 s ) undoubtedly afford the best means of com- 
bating the anhydremia and of restoring the failing circula- 
tion. Rectal injections of hot tannic solutions (2 per cent), as 
strongly recommended by Cantani, may also be used. The 
body-temperature should be maintained by hot applications 
or hot baths. Diffusible stimulants, like ether and camphor, 
may be given hypodermically. 

To allay thirst, ice, ice-water, or iced Seltzer water may be 
given at frequent intervals. The painful cramps are best treated 
by warm applications, hot baths, gentle friction with anodyne 
liniments, and, above all, by intermittent chloroform inhala- 
tions. In suppression of urine the most promising measures 
are dry cupping over the loins, and rectal and intravenous in- 
jections of saline solutions. 

Reaction Stage. — In this stage liquid foods in small 
quantities are permissible. Milk with lime-water, whey, thin 
gruels, albumin-water, and light broths are the most appro- 
priate. The return to ordinary food should be effected most 
gradually. Water should be given freely, since it tends to 
restore vascular fulness and favors diuresis. Any tendency to 
recurrent diarrhea should be met by the administration of bis- 
muth subnitrate with an intestinal antiseptic or of silver and 
opium pills. Bitter tonics are often of service during con- 
valescence. Change of air is a valuable aid to the restoration 
of health. 

WHOOPING-COUGH. 

The , chief elements in the prophylaxis of whooping-cough 
are isolation of the patient and the thorough disinfection of all 
articles that have been used by him. Quarantine should last 
until the cough ceases, which will seldom be before the end 
of six or eight weeks from the onset of the disease. 

As there is no specific, treatment must be directed to reliev- 
ing the catarrh, allaying the irritability of the respiratory 
mucous membrane, and warding off complications. Fresh air, 
sunlight, protection from changes of weather, and a light but 
nutritious diet are essential. In some cases it may be desirable 
to keep the patient in his room, or even in bed, for the first few 
days, but ordinarily, if the weather be good, he need not be 
confined indoors. In advanced cases sea air often acts most 
favorably. In some instances, when the vomiting is very per- 
sistent, it may be desirable to withhold food by the mouth for 
a short period and to substitute nutritive enemata. 

Expectorants are rarely of service except in the first stage, 



ACUTE INFECTIOUS DISEASES. 533 

when the cough lacks the distinctive whoop and is hard and 
dry. At this period a mixture of potassium citrate, ipecac, 
and paregoric (see p. 528) may be useful in rendering the ex- 
pectoration less viscid. 

Special Remedies. — Of the numerous special remedies 
advocated, the chief are belladonna, quinin, bromids, antipyrin, 
bromoform, and alum. No one drug is of service in every 
case, and after failing with one, another should be tried. Bella- 
donna has a long-established reputation ; to be effective, it must 
be given in ascending doses until a constitutional impression is 
perceptible (see p. 80). Quinin, first recommended by Letzer- 
ich, is undoubtedly of value in many cases ; it must be given, 
however, in large doses, — 10-12 gr. (0.65-0.8 gm.) a day for a 
child of three or four years, — and these may disturb digestion. 
The bromids, especially of sodium and strontium, are often of 
service in lessening the frequency and severity of the parox- 
ysms. They may often be advantageously combined with 
belladonna. Antipyrin has been advocated since 1886, and is, 
on the whole, perhaps, the most reliable remedy. The dose 
should be gradually increased until a child one year old receives 
from j— 1 gr. (0.03-0.06 gm.) every two hours. It is particu- 
larly efficacious in combination with a bromid, as in the fol- 
lowing formula : 

R Sodii bromidi, gr. 1 (3.2 gm.) ; 

Antipyrinse, gr. xv (1.0 gm.) ; 

Glycerini, fjjss (15.0 c.c.) ; 

Aquae menthae piperitae, q. s. ad f^iij (90.0 c.c). M. 
Sig. — A teaspoonful every two hours for a child one year old. 

Bromoform, introduced by Stepp in 1887, has been warmly 
recommended by Fischer, Burton-Fanning, and others. The 
initial dose for a child under two years of age should not 
exceed 1 min. (0.06 c.c.) four times a day (see p. 117). 

Alum is a very old remedy ; in small doses — 1 gr. (0.06 gm.) 
every two hours for a child of one year — it is occasionally 
useful when there is copious secretion. 

Chloral (3 gr. — 0.2 gm. — for a child of two years) or Dover's 
powder (1 gr. — 0.06 gm.) may be given in severe cases at bed- 
time to secure sleep. The inhalation of chloroform or of 
amyl nitrite may be necessary when the paroxysms are so 
violent as to threaten hemorrhage or convulsions. 

For the prevention of excessive vomiting, Kilmer highly 
recommends the application of an abdominal belt made of 
linen, with a strip of elastic webbing two inches wide, inserted 
on each side. The belt extends from the axillae to the pubes 
and laces in the back. 



534 APPLIED THERAPEUTICS. 

I/OCal Treatment. — Mild but persistent counterirritation 
over the chest is sometimes useful, particularly when the catar- 
rhal element is prominent. Medicated steam inhalations with 
eucalyptol, benzoin, creasote, or terebene are also very bene- 
ficial when there is excessive bronchitis or a pneumonic com- 
plication. Good effects have been claimed for oxygen and 
ozone inhalations. Antiseptic and sedative sprays, when feasi- 
ble, sometimes afford much relief; the best are the solution 
of hydrogen dioxid (i part to 6 parts of water), menthol (5-10 
per cent, in liquid paraffin), resorcin (1 per cent, aqueous solu- 
tion). Insufflations of drugs in the form of a fine powder — 
quinin, bode acid, tannin, benzoin, etc. — have been warmly 
advocated by many, but they are of doubtful benefit. 

Convalescence. — During convalescence it is necessary to 
exercise considerable care, on account of the great danger of 
catarrhal pneumonia. Tonics, especially quinin, iron, and cod- 
liver oil, are very useful. When there is persistent enlarge- 
ment of the bronchial glands, iodid of iron internally, with 
inunctions of europhen (5 per cent), will be found efficacious. 
Change of air is always beneficial. 



ERYSIPELAS. 

As in other contagious diseases, isolation and disinfection 
are the most important prophylactic measures. Especially 
necessary is it to guard parturient and surgical patients from 
the contagion. 

Internal Treatment. — A supporting liquid diet should be 
given. Alcoholic stimulants are sometimes required in con- 
siderable quantities. High fever is best controlled by cold 
sponging or the cold pack. Restlessness, delirium, and insom- 
nia will call for applications of ice to the head, and perhaps 
the administration of morphin, chloral, or bromids. 

Of the numerous special remedies recommended for erysip- 
elas, the one which has enjoyed the most favor is the tincture 
of ferric chlorid (20-30 min. — 1.2-2.0 c.c. — every three hours), 
first suggested by Bell in 185 1. While apparently of some 
service, this drug is not a specific, and should be withdrawn if 
it disturbs digestion. The therapeutic status of antistrepto- 
coccus serum has not yet been definitely determined, although 
it has been frequently administered in severe cases with alleged 
good results. 

I/OCal Treatment. — Among the numerous local applica- 
tions recommended for erysipelas may be mentioned mixtures 
of zinc oxid, boric acid, and starch on cotton-wool ; lotions of 



ACUTE INFECTIOUS DISEASES. 535 

lead- water and laudanum, of carbolic acid (1 : 40), of corrosive 
sublimate (1 : 5000), of picric acid (1 : 100), and of magnesium 
sulphate (saturated aqueous solution on a mask of from 1 5 to 
20 thicknesses of gauze) ; and ointments of ichthyol (30 per 
cent.) and of soluble silver (15 per cent). In the author's 
hand, ichthyol (see p. 335) and soluble silver (see p. 374) have 
proved the most satisfactory local remedies. 

Eschars made with the stick of silver nitrate or strong car- 
bolic acid beyond the infected area are occasionally successful 
in arresting the spread of the disease. The cellular infiltration 
caused by these irritants probably serves to check the migra- 
tion of the cocci. The injection of antiseptics, such as car- 
bolic acid and corrosive sublimate, around the diseased area is 
of very doubtful utility. 

Local abscesses should be incised and treated antiseptically. 
Extension to the nose and throat will call for antiseptic sprays 
or washes. Should the larynx become involved, the constant 
sucking of ice may serve to control the swelling ; whenever, 
however, dyspnea becomes urgent, scarification of the larynx 
or tracheotomy will be demanded. 



TETANUS. 

The most important safeguard against the occurrence of 
tetanus is the thorough cleansing and disinfection of all wounds. 
As tetanus antitoxin is practically harmless and has been shown 
to possess considerable immunizing power, it is advisable to 
employ it as a prophylactic remedy in all suspicious wounds, 
especially those which have become contaminated with garden 
earth, street dirt, or stable refuse. 

When tetanus has actually developed, the indications for 
treatment are to prevent the further production of toxin at the 
seat of injury ; to neutralize the toxin that has already been 
absorbed and is exerting a baneful influence on the nervous 
system ; to subdue the convulsions ; and to maintain nutrition 
until the disease shall have run its course. 

The first indication is to be met by promptly enlarging the 
wound, freeing it from all foreign matter, and treating it with 
some active antiseptic. The most hopeful means of meeting 
the second indication is by administering tetanus antitoxin (see 
p. 432). Of 290 cases of tetanus treated by the subcutaneous 
injection of serum, death occurred in 117 (Moschowitz). 1 While 
an analysis of the statistics does not justify the conclusion that 
antitoxin is very potent in acute cases, it does suggest that the 

l Medical News, October 13, 1900. 



536 APPLIED THERAPEUTICS. 

remedy is of distinct value in subacute and chronic tetanus. 
As no ill effects result from the administration of the serum, 
and as its use does not interfere in any way with other methods 
of treatment, we believe that it should be used in large doses 
in every case, and as soon as possible after the onset of the 
symptoms. When the symptoms are grave it would seem to 
be advisable to inject the serum directly into the brain or into 
the subarachnoid space of the spinal cord. Forty-eight cases 
treated by cerebral injections presented a little over 50 per 
cent, of recoveries. All these cases, however, were of the 
severest type (Moschowitz). According to von Leyden, of 
II severe cases treated by subarachnoid injections, recovery 
occurred in the last 5. 

Bacelli has reported excellent results (1 death in 40 cases) 
in the treatment of tetanus from the subcutaneous administra- 
tion of carbolic acid in large doses (see p. 389), but other 
observers outside of Italy have not been able to repeat his 
success. It is not improbable that tetanus runs a milder course 
in Italy (PfeifTer). As the central nervous system seems to 
possess some antitoxic power, the injection of brain-substance 
subcutaneously has been recommended. 

The drugs most effective in subduing convulsions are the 
bromids and chloral. These should be given in large doses. 
Morphinand eserin are useful adjuvants. Subarachnoid injec- 
tions of magnesium sulphate (see p. 217) have yielded satis- 
factory results in a few cases. Inhalations of chloroform or 
of amyl nitrite sometimes afford temporary relief. Of course, 
the patient should be kept absolutely quiet and protected from 
cold and from even the slightest external irritation. 

The maintenance of nutrition by the administration of nutri- 
ment in liberal quantities is of the utmost importance. In 
severe cases, milk, raw eggs, and animal broths are suitable 
forms of nourishment. Alcohol is often necessary, sometimes 
in large quantities. When swallowing is impossible, feeding 
must be carried out by means of a tube passed through the 
nostril. 



RHEUMATIC FEVER, 

General Management. — Absolute rest in a comfortable 
bed is essential, and, with the view of preventing permanent 
injury to the heart, this should be maintained for at least ten 
days or two weeks after the temperature has become normal 
and all the arthritic symptoms have subsided. To guard 
against chilling of the body, the patient should wear a loose 



ACUTE INFECTIOUS DISEASES. 537 

flannel night-dress and lie between blankets. The room should 
be well ventilated, but free from draft. Milk and cereals are 
the most suitable articles of diet. Junket, koumiss, ice-cream, 
milk-toast, boiled rice, and gruels may be given. During the 
febrile period animal food is best avoided. During convales- 
cence, however, fish, oysters, eggs, and broths are admissible. 
The free use of water and of lemonade should be encouraged. 
Alcohol, unless the heart is seriously involved, is not often 
required. 

Internal Treatment. — Salicylic compounds have consid- 
erable power in mitigating pain, shortening the duration of the 
attack, and of lessening the liability to cardiac complications. 
The more typical the case, the more decided are the good 
effects of these drugs. From 10 to 15 gr. (0.65-1.0 gm.) of 
ammonium or sodium salicylate should be given every two or 
three hours, until a decided impression is made upon the dis- 
ease or the phenomena of salicylism are produced, when the 
interval between the doses should be lengthened to four or six 
hours. It is advisable to continue the drug for several days 
after the subsidence of the symptoms. When the ammonium 
or sodium salt is not well borne, strontium salicylate (see p. 
399) or aspirin may be substituted. 

Alkalis are also remedies of value ; they may be combined 
with the salicylates or they may be given alone. About 
20 gr. (1.3 gm.) of potassium citrate or acetate should be given 
every two or three hours until the urine becomes decidedly 
alkaline ; then every four or six hours, the influence of the 
remedy being maintained for at least a week after all symptoms 
have disappeared. 

Opium, in the form of Dover's powder or of morphin hypo- 
dermically, is sometimes of great value in allaying pain, sub- 
duing restlessness, and procuring sleep. Antipyrin or phe- 
nacetin, in moderate doses, is also a useful adjuvant to salicy- 
lates or alkalis when the pain is severe. When adynamia is 
marked, quinin (5 gr. — 0.3 gm. — thrice daily), as recommended 
by Garrod, Duckworth, and DaCosta, is frequently beneficial. 
Anemic patients are usually benefited by iron. A useful com- 
bination is the ferrosalicylate mixture recommended by S. S. 
Cohen : 

R Sodii salicylates, ^iij (12.0 gm.) ; 

Glycerini, fgvj (22.5 c.c.) ; 

Mucilaginis acacise, f^iij (12.0 c.c); 

Olei gaultheriae, Tltxij (0.8 c.c); 

Liquoris ammonii citratis (B. P.), f^iss (45.0 c.c) ; 
Solve et adde guttatim, 

Tincturae ferri chloridi, fjiij (12.0 c.c). M. 

Sig. — One to two teaspoonfuls in water every three hours. 



538 APPLIED THERAPEUTICS. 

In some cases, when the usual remedies prove unsatisfactory, 
syrup of iodid of iron, in large doses (1-3 fl. dr. — 4.0-1 1.0 c.c. 
— daily), as recommended by J. C. Wilson, is quite effectual. 

Hyperpyrexia is best controlled by the cold bath (see p. 
493). The treatment of endocarditis and of pericarditis will 
be treated in another part of this volume. The importance of 
prolonged rest in cases in which the heart becomes affected 
cannot be overestimated. During convalescence, tonics, like 
iron, quinin, and arsenic, and a liberal diet are necessary. 

I/Ocal Treatment. — In mild cases the application of cot- 
ton-wool to the affected joints will suffice. When the pain is 
severe, hot alkaline lotions sometimes afford relief; but, as a 
rule, compresses soaked in methyl salicylate and covered with 
oiled paper are much more effective. Ointments containing 
salicylic acid (see p. 398) are also useful. In some cases small 
blisters applied about the inflamed joints are of great utility. 
According to Osier, however, they are not nearly so beneficial 
as light applications of the thermocautery. 

No matter what local remedy is selected, it is very impor- 
tant that the affected joints should be kept at complete rest. 
This may be accomplished by means of padded splints and a 
roller bandage or, often better, by the use of starch bandages 
or plaster casts. 

Lingering swelling will often yield to an ointment of mer- 
cury and belladonna, with firm strapping of the articulation. 
Blisters are also useful. When the effusion is very great and 
persistent, it may be necessary to aspirate the joint. 

For the stiffness of the joints induced by rheumatism, mas- 
sage, warm baths, and inunctions with an ointment of iodin 
will be found useful. The hot-air treatment (see p. 485) also 
does good in some cases. 

MUMPS. 

In the majority of cases but little treatment is required. The 
patient should be confined to a warm room and preferably to 
bed. Isolation should last about three weeks from the onset 
of the disease. As deglutition is painful, the nourishment must 
be fluid. A mild aperient may be administered at the outset. 
If febrile symptoms are marked, refrigerants, like aconite, spirit 
of nitrous ether, and solution of ammonium acetate will be 
found useful (for formula, see p. 63). Pain in the throat is 
best relieved by sucking ice. 

I/Ocal Treatment. — In mild cases, covering the gland 
with cotton batting will be all that is necessary. When there 



CONSTITUTIONAL DISEASES. 539 

is decided pain, hot fomentations proove soothing. Emollient 
applications with laudanum (1 fl. dr. to 1 oz. — 4.0 c.c. to 30.0 
gm.) are frequently recommended. An ointment of guaiacol 
(5 per cent.) has recently been warmly advocated. 

Orchitis will require rest, suspension of the affected gland, 
and the application of lead-water and laudanum or, better still, 
of an ointment of guaiacol (10 per cent). After the tender- 
ness has subsided, an ointment of mercury and belladonna will 
be found useful in reducing the swelling. 



CONSTITUTIONAL DISEASES. 

DIABETES MELLITUS. 

The treatment of diabetes mellitus is dietetic, hygienic, and 
medicinal. 

Dietetic Treatment. — The general rule is to eliminate 
from the dietary, at least for a time, all starchy and saccharin 
foods. Some relaxation of this rigid rule, however, is often 
desirable and even necessary. Each case must be carefully 
studied from the standpoint of the urine, the body-weight, 
and the general health. In mild types of the disease, after 
the glycosuria has once been controlled by strict dietetic 
regimen, it is generally possible to add a certain amount of 
carbohydrate matter without causing the reappearance of 
sugar in the urine. The exact amount and character of the 
carbohydrates that can be tolerated should be determined in 
each instance by frequent quantitative estimations of the sugar 
excreted. Again, in severe cases it is frequently necessary, in 
spite of some increase of glycosuria, to permit greater latitude 
in diet, in order to sustain the patient's strength. " There can 
be no doubt that a diabetic patient whose strength is well 
maintained is better off than one whose urine contains only 1 
per cent, of sugar, but yet is daily growing weaker " (Striimpell). 

The strict diet precludes the use of the following articles : 
bread, cakes, and pastry made of wheat, rye, rice, or corn, 
sago, barley, tapioca, beets, carrots, turnips, parsnips, peas, sweet 
fruits, chestnuts, chocolate, syrup, preserves, sweet wines, malt 
liquors, cordials, and all preparations containing cane-sugar or 
glucose. 

Potatoes are generally classed among the forbidden articles, 
but Mosse and Saundby have shown that they are not only 
permissible in many cases, but even useful. Mosse advances 
two hypotheses to explain the beneficial action of potatoes ; 
the first is that they yield a sugar more easily warehoused 



540 APPLIED THERAPEUTICS. 

than that from bread ; and second, that they introduce a sub- 
stance (potash) into the organism which favors glycolysis. 
The following articles may be allowed : 

Animal Food. — Meats of various kinds (except liver), game, 
light broths and soups, fish, and eggs. Fats, when well digested, 
are beneficial and may be taken freely. 

Vegetables. — Spinach, cabbage, Brussels sprouts, cauliflower, 
celery, lettuce, water-cress, string-beans, young onions, toma- 
toes, mushrooms, asparagus tips, cucumbers, and dandelion. 

Bread. — In very many cases a small amount (2 or 3 ounces 
a day) of bran bread or whole-wheat bread may be permitted. 
Gluten bread is also used, but most so-called gluten flours 
contain a large percentage of starch. Many substitutes have 
been recommended for wheat bread, but even the best of these 
are rather unpalatable and heavy. The best known are bread 
or biscuit made of pure bran (Prout), of almond meal (Pavy), 
of inulin (Kulz), of Soya bean (Dujardin-Beaumetz), and of 
aleuronat, a glutinous flour obtained as a by-product in the 
manufacture of starch (Ebstein, von Noorden). 

Beverages. — Buttermilk, skimmed milk, carbonated waters, 
mineral waters (Vichy, Carlsbad, Vals, and Saratoga), tea and 
coffee without sugar, and alcoholic beverages containing little 
or no sugar (claret, Rhine wines, dry Moselle, Bordeaux, dry 
sherry, well diluted brandy or whisky). No restriction should 
be placed on the amount of water desired. 

Relishes. — Caviare, olives, pickles, and cheese. 

Fruits and Nuts. — Grape-fruit, lemons, sour cherries, cran- 
berries, red currants, and nuts (except chestnuts) are allowable 
in small quantities. 

Sweetening Agents. — Certain forms of sugar appear to be 
assimilable. Thus milk, although it contains a considerable 
quantity of lactose, is usually well borne. Levulose (see p. 
473), also in moderate amounts, seems to be harmless. The 
chief substitutes for sugar are saccharin and glycerin. 

Hygienic Treatment. — Fresh air and systematic exercise 
are of great value. The patient must be warned, however, 
against overexertion. Moderation must be observed in all 
things. Flannel should be worn next to the skin, and all 
undue exposure avoided. Massage has been strongly recom- 
mended. Hydrotherapy, as first suggested by Bouchardat, is 
decidedly efficacious. If the patient is vigorous, Turkish baths 
may prove useful. Diabetics who still possess a fair measure 
of health frequently derive much benefit from a visit to certain 
mineral springs, such as Neuenahr, Homburg, Carlsbad, and 
Vichy. Obese, gouty subjects often do remarkably well at 
Carlsbad. 



CONSTITUTIONAL DISEASES. 54 1 

Medicinal Treatment. — The medicinal treatment of dia- 
betes is purely empiric. The drugs which have been shown to 
be of most value are opium, bromids, salicylic compounds, 
antipyrin, alkalis, and arsenic. 

Opium is generally the most reliable drug, especially in the 
severe nervous cases. It relieves thirst, promotes sleep, allays 
restlessness, and diminishes the excretion of urine and sugar. 
Patients can often take with advantage from 5-8 gr. (0.3-0.5 
gm.) a day. Upon the disappearance of the symptoms it 
should be gradually withdrawn. Saline aperients may be 
associated with it, when necessary, to prevent constipation. 
Codein is sometimes preferable to opium. Doses of \ gr. 
(0.03 gm.), thrice daily, may be gradually increased until the 
glycosuria disappears or ceases to be affected. 

Bromids, either alone or as adjuvants to opium, are very 
useful in subduing nervous symptoms. Salicylic compounds 
rank next in efficacy to opium. While they yield the best 
results in gouty cases, their good effects are by no means lim- 
ited to that class. From 40-80 gr. (2.5-5.0 gm.) of strontium 
or ammonium salicylate may be given in the twenty-four hours. 
This treatment should be discontinued upon the slightest evi- 
dence of intolerance. 

Some cases do remarkably well upon antipyrin in doses of 
from 10-15 gr. (0.6-1.0 gm.) thrice daily. It may often be 
combined advantageously with an alkaline carbonate, salicylate, 
or bromid. 

Alkaline carbonates and alkaline mineral waters have long 
enjoyed a reputation as remedies in diabetes. While they do 
not appear to have a decided influence on the glycosuria, they 
often relieve dyspeptic symptoms and constipation and tend to 
avert coma. Arsenic, especially in the form of the so-called 
bromid of arsenic or Clemens' solution (see p. 312), occasionally 
succeeds when other remedies fail. 

Cod-liver oil, strychnin, iron, and alcohol are useful at times 
in meeting special indications. 

Among other remedies which have been recommended, but 
which are of somewhat doubtful utility, may be mentioned: 
Jambul (Banatvala), uranium nitrate (West), glycolytic ferment 
from the pancreas (Lepine), ergot (Dougall), and calcium car- 
bonate and phosphate (Grube). 

Special Symptoms. — Constipation \s best treated by saline 
cathartics or the alkaline mineral waters. Remedies which 
lessen the polyuria also serve to quench the thirst. Acidulous 
drinks are sometimes of service. 

Pruritus of the genitals should be treated by frequent spong- 



54 2 APPLIED THERAPEUTICS. 

ing, especially after micturition, with a saturated solution of 
boric acid. Lotions containing carbolic acid, resorcin (see p. 
393), or sodium hyposulphite may also be tried. 

Diabetic Coma. — When coma is threatened, prophylactic 
treatment consists in substituting milk with some carbohy- 
drate for the strict proteid dietary, in the administration of 
sodium bicarbonate, — an ounce (31.0 gm.) or more a day, — in 
keeping the bowels freely opened with saline aperients, and in 
sustaining the circulation with strychnin and whisky. In the 
presence of actual coma treatment is usually unavailing. The 
most useful measure is the intravenous injection of a 2 to 3 per 
cent, solution of sodium bicarbonate to the extent of 1 or 2 
pints (0.5-1.0). To insure rapid action of the bowels, a brisk 
cathartic (croton oil) should be given. Hypodermic injections 
of ether and strychnin are useful. The inhalation of oxygen 
has been highly recommended. 

DIABETES INSIPIDUS. 

The hygienic treatment suggested for diabetes mellitus is 
applicable in diabetes insipidus. The patient should have a 
nutritious but digestible diet. No benefit is derived from re- 
stricting the quantity of water desired. Acidulated drinks, 
like lemonade, aid in assuaging thirst. Many remedies have 
been recommended; those possessing the most extended 
reputation are opium (4-8 gr. — 0.25-0.5 gm. a day), valerian 
(|— 1 fl. oz. — 15.0-30.0 c.c. of ammoniated tincture daily), ergot 
(•|— I dr. — 2.0-4.O gm. of the extract or of ergotin daily), anti- 
pyrin (10 gr. — 0.6 gm. three or four times a day), bella- 
donna (5 min. — 0.3 c.c. of the tincture three times a day, the 
dose being gradually increased), and gallic acid (1 dr. — 4.0 gm. 
a day). Galvanism — one pole applied to the neck and the other 
to the loins — has also been recommended. Tonics — cod-liver 
oil, iron, and strychnin — are sometimes required. In syphilitic 
cases good results may be anticipated from a thorough trial of 
mercury and potassium iodid. The dryness of the skin may 
be relieved by warm baths, followed by inunctions with olive 
oil (Saundby). 

GOUT. 

Chronic Gout. — No absolute rule can be laid down regard- 
ing the diet. The special features in each case should receive 
careful study. Some patients do well upon a non-proteid diet, 
others do not. Simplicity and moderation are of the utmost 
importance. Generally speaking, a diet composed for the 



CONSTITUTIONAL DISEASES. 543 

most part of milk, farinaceous foods, succulent vegetables, 
eggs, nsh, and lean meats is most suitable. The foods most 
likely to disagree are veal, liver, sweetbreads, hashes, croquettes, 
concentrated soups, vegetables rich in nucleins, — peas and 
beans, — pastry, sweets, coffee, malt liquors, and heavy wines. 
Some patients are exceedingly intolerant of acid fruit. Milk 
taken as a beverage at meals is objectionable. Alcoholic 
stimulants, as a rule, should be avoided; occasionally, how- 
ever, a small quantity of well-diluted whisky at meals aids 
digestion and is well borne. Water-drinking between meals 
should be encouraged. 

The quantity as well as the character of the food must be 
regulated. No more should be eaten than is absolutely neces- 
sary to satisfy hunger. The patient should be warmly clothed 
and should avoid as far as possible exposure to sudden atmos- 
pheric changes. Systematic exercise in the open air is ex- 
tremely beneficial. Well-nourished patients should be urged 
to take walking trips, to play golf or tennis, or to try horse- 
back riding. When active exercise is not feasible, massage 
may be strongly recommended. All overwork of mind should 
be forbidden. Hydrotherapy — tepid sponge-baths and douches 
— is useful. Heavy robust patients often derive much benefit 
from the Turkish bath. 

Visits to certain mineral springs — Bedford, Saratoga, Har- 
rowgate, Carlsbad, Contrexeville, Aix-les-Bains — are some- 
times of the greatest value. The good effects of the spa treat- 
ment are only in part due to the waters drunk : change of 
scene, fresh air, strict diet, and freedom from business and 
household cares are important factors. Residence during the 
winter months in a dry, warm, inland climate is desirable. 

Remedies calculated to improve digestion are frequently 
indicated. In some cases a combination of an alkali with a 
bitter (see p. 175) before meals is of much service. Daily 
action of the bowels should be secured. The occasional use 
of calomel or blue-mass at night, with a saline in the morning, 
is often of value. Among the special remedies advocated for 
gout may be mentioned alkalis and alkaline mineral waters, 
colchicum, guaiac, arsenic, and iodids. 

Of these, the alkalis, especially the vegetable salts of potas- 
sium, are the most useful (see pp. 226, 231, 243). Colchicum 
is most effective in the acute paroxysms, although small doses 
with alkalis may be of benefit in the interval. Guaiac (see p. 
338) probably ranks next in efficacy to the alkalis. The 
prolonged use of arsenic in small doses has seemed to us to 
be of some value. Iodids are sometimes of service in relieving 



544 APPLIED THERAPEUTICS. 

the concomitants and sequels of gout, — arthritis, bronchitis, 
arteriosclerosis, — but have little, if any, effect upon the disease 
itself. Salicylates relieve pain, but are distinctly inferior to 
colchicum. Such remedies as piperazin, lycetol, and quinic 
acid (see p. 244) are of doubtful utility. 

Chronic affections of the joints are best treated by gentle 
massage, friction, and warm sulphur baths. 

Acute Gout. — The most efficient remedy is colchicum; 
from 5-10 min. (0.3-0.6 gm.) of the wine may be given well 
diluted three or four times a day. It should be stopped as 
soon as relief is obtained. Alkalis are useful adjuvants (for 
formula, see p. 338). Water-drinking should be encouraged. 
At the outset a brisk mercurial purgative, followed by a saline, 
is usually advisable. Excruciating pain will demand the use 
of morphin. Phenacetin is sometimes effective. The diet 
should be light and non-stimulating. 

The affected part should be elevated and wrapped in cotton- 
wool or covered with cloths soaked in lead-water and laudanum. 

CHRONIC RHEUMATISM. 

Strict attention should be paid to hygiene. The patient 
should be warmly clothed, wool or silk being next to the skin, 
and great care should be taken to guard against wet and sud- 
den changes of temperature. The food should be nourishing, 
but digestible. Fatty foods, when well borne, are of much 
value. Hot sulphur and hot saline baths are often very use- 
ful. Massage and Swedish movements are excellent adjuvants 
to hydrotherapy. Vigorous patients may be benefited by 
Turkish baths. Residence in a dry, warm, equable climate — 
Southern California, Arizona, Riviera, Egypt — especially dur- 
ing the changeable seasons, is always desirable. 

Tonics and certain alteratives, such as cod-liver oil, iron, and 
arsenic, are the most generally useful internal remedies. Iodides 
are sometimes of service, but on the whole they are inferior 
to arsenic. Salicylates are efficacious in relieving acute ex- 
acerbations, but they have no permanent effect. Colchicum is 
useless. Guaiac, sulphur, cimicifuga, ichthyol, and many other 
drugs have been recommended. 

I/OCal Treatment. — Massage, if employed systematically, 
often accomplishes much good. Superheated air-baths are 
occasionally useful. Electricity is of little value. Rubefacient 
liniments have a palliative influence in mild cases. An oint- 
ment of mercury, belladonna, and ichthyol, well rubbed into 



CONSTITUTIONAL DISEASES. 545 

the affected part, is sometimes very efficacious. When the 
pain is severe and persistent, blisters ©r light applications of 
the actual cautery prove effective. 



MUSCULAR RHEUMATISM, 

In mild cases it will suffice to put the affected muscles at 
rest. In pleurodynia this is accomplished best by strapping 
the affected side as in fracture of the ribs, and in lumbago by 
applying a large piece of adhesive plaster from the floating ribs 
to the iliac crests. In more severe cases it will be necessary 
to apply rubefacient liniments, sinapisms, or, better still, hot 
fomentations, and to administer a salicylate, combined, per- 
haps, with a coal-tar analgesic : 

R Salophen, gij (8.0 gm.) ; 

Acetphenetidini, ^j (4.0 gm.). M. 

Fiant chartulse No. xii. 
Sig. — One every three hours. 

A rubefacient ointment like the following is often efficacious : 

R Methylis salicylatis, gss (2.0 c.c.) ; 

Guaiacolis, TTLxx (1.3 c.c.) ; 

Mentholis, gr. xx (1.3 gm.); 

Adipis, 5ij (8.0 gm.); 

Cerati, 5iiss (10.0 gm.). M. 

Sig. — Rub in a small quantity over seat of pain twice daily. 

A blister is occasionally required. When the pain is intense, 
hypodermic injections of morphin (J gr. — 0.016 gm.) with atro- 
pin (y^-Q- gr.— 0.0005 g m w ^ afford great relief. In lumbago, 
acupuncture (see p. 438) sometimes yields excellent results. 
Hot packs and baths are often efficacious, but great care must 
be exercised to guard against exposure after their use. Per- 
sistent myalgia is often very favorably affected by massage and 
applications of the faradic current. In chronic cases, potas- 
sium iodid and guaiac should be tried. Gelsemium in large 
doses (Brunton) and ammonium chlorid (Anstie, Ringer, 
Roberts, DaCosta) have also been recommended. 



RHEUMATOID ARTHRITIS. 

The most that can be expected from treatment is ameliora- 
tion of the symptoms, and, perhaps, some retardation of the 
progress of the disease. The hygienic treatment is as for 

35 



546 APPLIED THERAPEUTICS. 

chronic rheumatism (see p. 544). An important indication is 
to maintain nutrition. Tonics are frequently necessary. Cod- 
liver oil in such doses as the stomach will tolerate is often very 
beneficial. The most satisfactory special agents are arsenic 
and the iodids, particularly the former. Garrod has repeatedly 
seen good effects follow the prolonged use of the syrup of 
ferrous iodid. Luff, in a large experience with the disease, has 
found guaiacol carbonate, 5 gr. (0.3 gm.), gradually increased 
to 15 gr. (1.0 gm.), thrice daily, an excellent adjuvant to the 
iodids. The remedies relied upon in gout are useless in 
rheumatoid arthritis. Salicylates are sometimes of service in 
acute exacerbations. Change of scene and climate, especially 
in the early period of the disease, frequently exerts a favorable 
influence. Visits to hot mineral springs (Hot Springs of Vir- 
ginia or Arkansas, Bath, Baden-Baden) are recommended. 

lyOcal Treatment. — Massage is of the greatest value in 
preserving the mobility of the joints and in maintaining the 
nutrition of the muscles. Acute exacerbations should be treated 
by rest and the application of cold compresses. Rubefacient 
liniments, inunctions with mild iodin or mercurial ointments, 
and small blisters are sometimes of benefit. The Bier method 
of producing hyperemia has been highly recommended. Elec- 
tricity and superheated air occasionally afford much relief; x- 
rays have yielded good results in a few instances. 

RHACHITIS. 

The treatment of rhachitis is mainly dietetic and hygienic. 
If the mother is deemed unfit for nursing, the child must be 
brought up by a wet-nurse or by hand. In most cases the 
latter method must be chosen. Generally speaking, the best 
substitute for natural food is diluted fresh cows' milk to which 
have been added cream and milk-sugar. The degree of dilution 
and the percentage of cream and sugar to be added will vary 
with the age of the infant and its power of assimilation. Lime- 
water and barley-water are the best diluents. Milk that has 
been partially predigested is in many cases an excellent food. 
Older children require undiluted milk, cream, beef-juice, veal- 
broth, eggs, scraped beef, pounded mutton, and fruit-juices. 
Starchy foods should be avoided. Very often it is necessary 
to correct digestive distuibaix^e^ oerore ordering a liberal diet. 

Fresh air, day and night, is essential. The child should be 
carefully protected, however, from the vicissitudes of the 
leather, and should be warmly clad in flannel. Sea-air is 
often very beneficial. Daily bathing, with friction and gentle 
massage, is to be recommended. 



DISEASES OF THE BLOOD AND DUCTLESS GLANDS. $47 

Dyspepsia, diarrhea, and constipation should receive appro- 
priate treatment. When well borne cod-liver oil is the best rem- 
edy. The dose should be increased gradually from a few minims 
to a teaspoonful, three or four times a day. When cod-liver oil 
cannot be taken by the mouth, it may be given by inunction 
(see p. 305). Phosphorus, which has been strongly recom- 
mended by Kassowitz and Jacobi, is of doubtful value (see p. 
300). The lactophosphate and hypophosphite of calcium are 
frequently combined with cod-liver oil for their tonic effect. 
Stoeltzner has obtained good results from the use of supra- 
renal extract, and Mendel, from the use of thymus extract. 
When there is anemia, an unirritating preparation of iron should 
be given. For the excessive sweating, atropin, in doses of -g-J-g- 
of a grain (0.0008 gm.) two or three times a day, has been 
recommended (Holt). 

DISEASES OF THE BLOOD AND DUCTLESS GLANDS, 

CHLOROSIS. 

Fresh air, sunlight, open-air exercise, and nourishing food 
are valuable aids in treatment. Change of climate or a sea- 
voyage is often beneficial. Very severe cases sometimes re- 
quire complete rest in bed and massage. If there be a good 
reaction, warm baths, followed by short cold douches, are effi- 
cacious. Iron is almost a specific. It is most frequently pre- 
scribed in the form of Blaud's pills (see p. 292), of which the 
dose is three pills, gradually increased to nine a day. In some 
cases other preparations of iron, such as iron and ammonium 
citrate, ammonioferric tartrate, albuminate, and pyrophosphate, 
are better borne. Laxatives, preferably mild salines, rank next 
in importance to iron, Arsenic is distinctly less valuable than 
iron. Bitters, such as nux vomica, gentian, and calumba, are 
often useful adjuvants, especially when there is anorexia with 
tardy digestion. Superacidity of the gastric juice is best treated 
by alkalis. 

PERNICIOUS ANEMIA. 

While the outlook in pernicious anemia is exceedingly grave, 
marked improvement and even apparent recovery are not im- 
possible. Fresh air, rest, and a diet as liberal as the digestive 
power of the patient will permit, are requisite. Rest in bed, 
warm salt baths, and massage are valuable adjuvants to inter- 
nal treatment. The teeth should receive careful attention. If 
there be gingivitis or pyorrhoea alveolaris, antiseptic mouth- 
washes should be used at frequent intervals. 



548 APPLIED THERAPEUTICS. 

Arsenic is the most valuable drug. It may be given in the 
form of Fowler's solution, the dose being gradually increased 
from 2 or 3 min. (0.1-0.2 c.c.) to 15 or 20 min. (1. 0-1.2 c.c.) 
three times a day. Iron is rarely of service, but may be tried 
when arsenic fails. Bone-marrow is sometimes efficacious. 
Dock has often used mercuric chlorid with benefit, not only in 
syphilitic cases, but also in others. Inhalations of oxygen 
have been recommended (Shattuck). Appropriate anthelmintic 
remedies should be given, of course, in the cases in which in- 
testinal parasites (Bothriocephalus latus, ankylostoma) are 
present. Digestive disturbances are often benefited by the 
administration of diluted hydrochloric acid and a bitter. 

LEUKEMIA, PSEUDOLEUKEMIA, AND SPLENIC ANEMIA. 

An effort should be made to maintain the general nutrition 
by regulating the diet and attending to hygienic measures. 
Rest is often advisable. Among drugs, arsenic appears to be 
of some service. Iron, quinin, and cod-liver oil occasionally 
are beneficial. Inhalations of oxygen may be tried. In pseudo- 
leukemia Gowers and Broadbent have found phosphorus of 
benefit. In leukemia, repeated applications of the Rontgen 
rays are sometimes followed by marked improvement, and 
even a symptomatic cure. A relapse, however, is to be ex- 
pected. According to Stengel and Pancoast, the best results 
are achieved when the rays are applied to the bones, various 
portions of the body being treated in succession, and the spleen 
not exposed until it is reduced considerably in size and the 
patient's general condition is much improved, and even then 
only w r ith caution. In neither leukemia nor pseudoleukemia 
is operative treatment of avail. In splenic anemia, however, 
removal of the spleen is a justifiable procedure. Of 32 cases 
of splenic anemia treated by splenectomy, in 23 recovery fol- 
lowed (Armstrong). 

SCURVY. 

The prime requisites in the treatment of scurvy are suitable 
nourishment and proper hygiene. Complete rest is generally 
advisable. The diet should include plenty of fresh vegetables, 
— potatoes, lettuce, cabbage, and onions, — with 3 or 4 ounces 
(90-120 c.c.) of lemon-juice daily. When the digestion is 
feeble and the gums are tender, it may be necessary to 'restrict 
the diet to such foods as beef-juice, animal broths, milk, raw 
e gg s > an d orange- or lemon-juice. Tonics, like iron, quinin, 
and strychnin, are often of service. In some cases alcoholic 
stimulants are required. The mouth should be cleansed at 



DISEASES OF THE BLOOD AND DLCTLESS GLANDS. 549 

frequent intervals with some antiseptic wash, such as D obeli's 
solution, and the spongy gums should be painted two or three 
times a day with a solution of silver nitrate, 20 grains (1.3 gm.) 
to the ounce (30.0 ex.). 

Infantile scurvy usually responds very promptly to correc- 
tion of the diet. The foods most worthy of confidence are 
fresh cows' milk, beef-juice, and orange-juice. 

PURPURA HAEMORRHAGICA. 

In many cases a favorable termination follows in the course 
of one or two weeks without special medication, while in others 
the disease progresses toward a fatal issue in spite of the most 
careful treatment. Hemostatics, both internal and external (see 
p. 377), are the remedies indicated. Great efficacy has been 
claimed especially for oil of turpentine, gelatin, and calcium 
chlorid. Heart-failure should be treated by cardiac stimulants, 
and restlessness and insomnia by opium in small doses. 
Secondary anemia will require iron and arsenic. 

HEMOPHILIA. 

The treatment of hemophilia is largely protective and pallia- 
tive. All operations liable to cause hemorrhage should be 
avoided. Bleeding will call for rest, the application of cold 
compresses and of styptics, and the administration of internal 
hemostatics (see p. 377). The drugs most worthy of confi- 
dence are, perhaps, gelatin and calcium chlorid. Weil, Labbe, 
and others have found fresh blood-serum markedly efficacious. 
It may be given in doses of 20 to 30 c.c. subcutaneously. The 
effect of the serum is at its height in twenty-four hours and lasts 
several weeks. The serum should not be over two weeks old ; 
human, horse, or rabbit serum may be used. In default of 
other varieties, fresh antidiphtheria serum may be employed. 
Combemale and Gaudier and Delace have used thyroid extract 
with asserted good results. Inhalations of oxygen have been 
strongly recommended. Wright advises inhalations of carbon 
dioxid when there is epistaxis. The resulting anemia is bene- 
fited by iron and arsenic. 

ADDISON'S DISEASE. 

As the primary lesion in Addison's disease is not amenable 
to therapeutic measures, little can be done beyond maintaining 
the patient's strength and relieving symptoms. Nutritious 
but readily digestible food, the avoidance of mental and phys- 
ical excitement, and good hygienic surroundings are important 



550 APPLIED THERAPEUTICS. 

factors in the treatment. When there is marked asthenia, 
absolute rest should be enjoined. Very marked improvement 
in the symptoms sometimes follows the administration of 
suprarenal extract (see p. 68). Tonics, like iron, arsenic, and 
strychnin, are of service. Irritability of the stomach will call 
for such sedatives as bismuth subnitrate, hydrocyanic acid, and 
cerium oxalate, and diarrhea for mild astringents and anti- 
septics. 

MYXEDEMA. 

As patients with myxedema are extremely susceptible to 
low temperatures, they should be warmly clad and protected 
from exposure to cold. Residence during the winter in a warm, 
sunny climate is desirable. Warm baths are often beneficial. 
Modern treatment consists in the administration of some prep- 
aration of thyroid gland (see p. 343). By continuing this rem- 
edy throughout life it is possible in many cases to hold the 
symptoms in complete abeyance. 

EXOPHTHALMIC GOITER. 

The general nutrition should be improved by rest, a gener- 
ous, readily digestible diet, healthy hygienic surroundings, and 
hydrotherapy. Residence in a warm seaside locality often 
promotes comfort and aids recovery. In severe cases absolute 
rest in bed is an essential point in the treatment. Applications 
of cold to the precordia, by means of Leiter's tubes or ice- 
bags, lessen the palpitation. 

Medicinal treatment is very uncertain. A drug that has 
been efficacious in one case may in another prove useless or 
harmful. Belladonna, recommended by Gowers, is undoubt- 
edly of value in many cases. It should be given in ascending 
doses until some dryness of the throat is produced. When 
the circulation is feeble, digitalis may be found of service ; on 
the other hand, when the heart is strong, better results may 
be obtained with aconite or veratrum viride. When anemia 
exists, iron is useful. Bromids are sometimes of service in 
controlling nervous symptoms. Starr has observed marked 
improvement from the use of sodium glycerophosphate in 
doses of 20 grains (1.3 gm.) three or four times a day, as 
originally recommended by Trachewsky. Mikulicz, Owen, 
Mackenzie, and others have found thymus extract (see p. 344) 
of some value. Musser has found small doses of opium suc- 
cessful in some cases. Among other remedies which have 
been recommended, but which are of more doubtful value, 
may be mentioned ergot, iodids, quinin hydrobromid, and 



DISEASES OF THE DIGESTIVE TRACT 55 1 

bromid of gold. The consensus of opinion is decidedly ad- 
verse to the use of thyroid extract. 

Specific antithyroid therapy has given encouraging results 
in a fairly large number of cases. The preparations chiefly 
used have been Moebius' serum (serum from thyroidectomized 
animals), thyroidectin (dried blood of thyroidectomized animals), 
rodagen (dried milk of thyroidectomized goats), and Beebe's 
and Rogers' serum (serum from horses inoculated with nu- 
cleoproteids and thyroglobulin from pathologic and normal 
thyroids). All these preparations are expensive. Of 86 pa- 
tients receiving specific treatment, except that of Beebe and 
Rogers, 80 were benefited and 6 were not (Bulkeley). Beebe 
and Rogers report 90 cases in which their serum was used, 
with the following results : 23 patients were cured, 52 im- 
proved, 1 1 not benefited, and 4 died. 

Galvanism (see p. 483) sometimes proves more effective in 
controlling the symptoms than any other remedy. Recently 
some very favorable results have been reported from the use of 
^■-rays. Finally, after other measures have been given a thorough 
trial, operative interference should be considered. Accord- 
ing to Rehn, in 177 partial excisions of the gland 57.6 per 
cent, of the patients were cured, 26.5 improved, 2.3 per cent, 
unimproved, and there were 13.6 per cent, of deaths. In 32 
resections of the sympathetic 31.1 per cent, were cured, 50 per 
cent, were improved, 12.5 per cent, were unimproved, and 
death occurred in 9.5 per cent. After ligation of the thyroid 
arteries in 14 cases 24 per cent were cured, 50 per cent, im- 
proved, and the remainder died. Of 59 cases operated on by 
Kocher, 45 were cured, 8 were decidedly improved, 2 were 
slightly improved, and 4 died from tetany as a result of the 
operation. Halstead has operated on 90 patients with 2 deaths 
and Mayo on 176 patients with 8 deaths. 

DISEASES OF THE DIGESTIVE TRACT. 

STOMATITIS. 

The source of the local irritation should be sought for and 
removed. Errors of hygiene should be corrected. The diet 
and the state of the alimentary tract should receive careful 
attention. The mucous membrane of the mouth should be 
washed at frequent intervals with cool antiseptic solutions. In 
mild catarrhal stomatitis a solution of boric acid, 5-10 gr. (0.3- 
0.6 gm.) to the ounce (30.0 c.c), will suffice. In obstinate cases 
the mouth, after being carefully cleansed, may be lightly painted 



552 APPLIED THERAPEUTICS. 

with a solution of silver nitrate, 4 gr. (0.26 gm.) to the ounce 
(30.0 c.c). Ulcers may be touched with solid silver nitrate or 
copper sulphate. 

In aphthous stomatitis a mild mercurial aperient is often of 
service. In addition to the frequent use of antiseptic washes 
(boric acid, potassium permanganate), the occasional applica- 
tion of silver nitrate — 10 gr. (0.6 gm.) to the ounce (30.0 c.c.) 
— is desirable. 

In thrush the mouth should be cleansed at frequent inter- 
vals, especially after every feeding, with one of the following 
solutions: sodium hyposulphite, 20 gr. (1.3 gm.) to the ounce 
(30.0 c.c); boric acid, 15 gr. (0.9 gm.) to the ounce (30.0 c.c); 
or potassium permanganate, 1 gr. (0.065 gm.) to the ounce 
(30.0 c.c). 

In ulcerative stomatitis potassium chlorate is almost a spe- 
cific It should be used both locally and internally (see p. 
231). The ulcers may be painted with a solution of silver 
nitrate, 10 gr. (0.6 gm.) to the ounce (30.0 c.c). Tonics, like 
quinin and iron, are called for in some instances. 

Gangrenous stomatitis demands energetic treatment. The 
sloughing surface and the tissue immediately surrounding it 
should be promptly destroyed under anesthesia with the actual 
cautery or strong nitric acid. After the operation the mouth 
should be cleansed at frequent intervals with a solution of 
hydrogen dioxid (1:3) or of potassium permanganate (1 per 
cent). Concentrated nutritious food, stimulants, and tonics 
are urgently indicated. 

The treatment of mercurial stomatitis has already been con- 
sidered (see p. 323). 

ACUTE PHARYNGITIS, 

In mild cases a gargle of potassium chlorate (see p. 368) 
will suffice. In severe cases the application to the throat of 
cloths wrung out of cold water proves grateful. The sucking 
of pieces of ice affords much relief. Gargles or sprays of the 
distillate of hamamelis (50 per cent.) are useful. A spray of 
menthol, 2 gr. (0.13 gm.) to the ounce (30.0 c.c.) of liquid 
petrolatum, is also efficacious. Lozenges containing cocain 
will often relieve pain and allay the tickling sensation in the 
throat. The following formula, recommended by Bosworth, 
answers the purpose admirably : 

R Cocainse hydrochloride gr. v (0.3 gm.); 

Extracti kramerise, gr. ij (0.13 gm.) ; 

Sodii bicarbonatis, gr. xv (1.0 gm.); 

Extracti glycyrrhizae, ^iiss (10.0 gm.). M. 
Fiant trochisci No. xxx. 



DISEASES OF THE DIGESTIVE TRACT. 553 

Internally, a mild aperient may be given at the outset. 
Sodium benzoate has a beneficial effect. From 5-10 gr. (0.3- 
0.6 gm.) may be given every three hours. Belladonna with 
aconite is also recommended. The rheumatic form usually 
yields promptly to a mild salicylic preparation, like salophen. 

CHRONIC PHARYNGITIS. 

The removal of the cause is of prime importance. All 
sources of local irritation, such as misuse and overuse of the 
voice, mouth-breathing, excessive smoking, and intemperance 
in eating and drinking must be avoided. Patients should be 
instructed to expel sounds by the aid of the diaphragm and 
abdominal muscles instead of the muscles of the throat. Nasal 
obstructions and adenoid growths must be removed. The 
habit of hawking and scraping to clear the throat should be 
rigidly interdicted. Digestive disturbances should receive 
careful attention. Tonics, like iron, strychnin, and cod-liver 
oil, are sometimes required. 

I/OCal Treatment. — The nasopharynx should be kept 
clean by frequent spraying with an antiseptic alkaline liquid, 
like Dobell's solution (see p. 172), Astringent applications 
are often of service ; one of the following may be employed : 
Zinc sulphate, 5 gr. (0.3 gm.) to the ounce (30.0 c.c.) ; tannin, 
1 dram (4.0 gm.) to the ounce (30.0 c.c.) of glycerin ; silver 
nitrate, 10-20 gr. (0.6-1.3 S m -) to tne ounce (30.0 c.c). In 
the follicular variety it is advisable to destroy the enlarged 
follicles by means of the galvanocautery, after which the 
astringent applications may be made. 

ACUTE TONSILLITIS. 

The patient should be confined to a warm room, and, if there 
be much fever, to bed. A mild aperient is indicated at the 
outset. The diet should be light but sustaining. The suck- 
ing of ice affords relief. The most reliable internal remedies 
are the salicylic compounds and sodium benzoate. They should 
be given in full doses at frequent intervals. Guaiac is also 
recommended. A dram (4.0 c.c.) of the ammoniated tincture 
of guaiac may be given in milk every three hours. Febrile 
symptoms, if pronounced, may be controlled by small doses 
of phenacetin or by a combination of aconite and spirit of 
nitrous ether (see p. 63). The pain may be so intense as to 
require the use of opium. 

I/OCal Treatment. — Externally, cold applications aid in 
bringing about resolution ; if, however, suppuration be inevi- 



554 APPLIED THERAPEUTICS. 

table, warm applications should be employed to hasten the 
process. Antiseptic sprays, like Dobell's solution (see p. 172) 
or a solution of hydrogen dioxid ( 1 14), are of benefit. Direct 
applications to the surface of the glands of the tincture of 
ferric chlorid — 1 dram (4.0 c.c.) to the ounce (30.0 c.c.) of 
glycerin or of a saturated ethereal solution of iodoform — are 
often useful. The treatment of follicular tonsillitis by the 
thorough application of very finely powdered aspirin, after the 
glands have been mopped with a warm solution of sodium 
bicarbonate, as recommended by Kieffer and Fetterolf, gives 
excellent results. Applications of dry sodium bicarbonate 
have also been highly recommended. 

Pus should be evacuated as soon as its presence can be 
detected. In the majority of cases it is best to make the in- 
cision not in the tonsil itself, but in the soft palate, a little above 
and to the outer side of the gland. 

ACUTE CATARRHAL GASTRITIS. 

Absolute rest is essential. If the stomach has not been 
completely emptied, an emetic, such as warm water or ipecac, 
should be employed. Locally, a mustard plaster or a turpen- 
tine stupe will aid in relieving distress. As a rule, no food 
should be given by the mouth until the stomach becomes 
retentive. Ice, however, may be allowed to quench the thirst. 
In delicate subjects nutrient enemata will be required. If 
there be constipation, a mercurial laxative may be given with 
advantage. Such a combination as the following usually acts 
favorably : 

R Hydrargyri chloridi mitis, gr. j (0.065 g 1 * 1 -) > 

Bismuthi subnitratis, gr. xx (1.3 gm.). M. 

Fiant chartulae No. vj. 

Sig. — One on the tongue every hour, to be followed by a Seidlitz 
powder, if necessary. 

Pain, nausea, restlessness, and insomnia are best relieved by 
opium suppositories or hypodermic injections of morphin. 
Sedatives by the mouth are also useful; thus, bismuth subni- 
trate may be given alone or combined with hydrocyanic acid 
(see p. 161), with creosote (\ min. — 0.03 c.c), or with cocain 
(l gr. — 0.0 1 gm.). The following combination of ipecac and 
nux vomica is often serviceable : 

5c Tincturse nucis vomicae, 

Vini ipecacuanhae, aa fgij (8.0 c.c). M. 

Sig. — Two drops every hour. 



DISEASES OF THE DIGESTIVE TRACT. 555 

After the lapse of twenty-four or thirty-six hours it is gen- 
erally possible to give bland nourishment by the mouth. 
Barley-water, champagne with soda-water, milk and lime- 
water, peptonized milk, and light broths may be given in small 
quantities at frequent intervals. The return to solid food should 
always be carried out very gradually. 

INDIGESTION. 

The first thing to be done in the treatment of all cases of 
indigestion is to find its cause, and to remove this, if possible. 
In many cases indigestion is merely a symptom of some con- 
stitutional disturbance, such as anemia, tuberculosis, Bright's 
disease, or diabetes, or is the result of passive hyperemia of the 
stomach induced by chronic cardiac, hepatic, or pulmonary 
disease. It is obvious that in such cases treatment must be 
directed very largely to the underlying condition. In the 
primary form of gastric indigestion the methods of eating and 
the character of the food are the factors of greatest importance. 
Regularity in the time of meals, slowness in eating, and thor- 
ough mastication of food must be insisted upon. The patient 
should be cautioned against overeating and the taking of large 
quantities of liquid, especially of iced water, during meals. 
Overindulgence in alcohol, tobacco, coffee, and tea should be 
forbidden. The resumption of mental or physical work imme- 
diately after meals should also be avoided. 

Dietetic Treatment. — It is impossible to lay down any 
absolute rules in the matter of diet. The conditions present in 
each case must receive careful study, and considerable allowance 
must be made for individual peculiarities. Generally speaking, 
such articles as fried meats, salted meats, pork, veal, hashes, 
croquettes, coarse vegetables and fruits, fried or boiled sweet 
and white potatoes, fresh bread, pastry, puddings, nuts, and 
malt liquors must be interdicted. In many cases of atonic 
dyspepsia (sub acidity), nervous dyspepsia, and mild gastric 
catarrh an ordinary mixed diet of readily digestible food is 
admissible. It may usually include boiled, baked, or grilled 
beef and mutton, chicken, sweetbread, boiled fish, oysters, 
soft-boiled or poached eggs, stale bread, toast, pulled bread, 
fresh butter, baked potato, young string-beans, small peas, 
spinach, hearts of celery, thoroughly cooked cereals (rice, 
wheat, oatmeal), baked apples, calves'-foot jelly, and junket. 
Tea, coffee, and cocoa may or may not be permissible. 

Indigestion associated with hyperacidity will require a bland, 
unirritating diet, composed largely of albuminous foods. A 



556 APPLIED THERAPEUTICS. 

moderate quantity of water or weak tea at meals is desirable. 
Condiments, spices, acids, oils, and alcoholic beverages are 
strongly contraindicated. 

When the expulsive power of the stomach is weak and there 
is a tendency to retention, the food should be nutritious and 
concentrated. Foods that are bulky and are liable to ferment 
should be avoided. Much fluid is undesirable. 

An exclusive milk diet sometimes acts exceedingly well in 
nervous dyspepsia and indigestion attended by hyperacidity. 
It is contraindicated when there is marked hypo-acidity, motor 
insufficiency, retention, or intestinal fermentation. 

Most cases do best without alcohol, but when there is pro- 
nounced subacidity or motor insufficiency, a small amount of 
diluted whisky, brandy, or sherry with meals may prove bene- 
ficial. Alcohol in any form is contraindicated when there is 
excessive secretion of acid or when there is hyperesthesia of 
the gastric mucosa. 

Generally, it is best to prescribe a definite bill-of-fare and to 
modify this from time to time as occasion demands. In de- 
termining the suitability of a given diet we must be guided 
chiefly by the patient's sensations and the state of his general 
nutrition. As a rule, no more than three meals a day should 
be allowed. When there is a tendency to retention, however, 
it may be advisable to give the food in smaller quantities and 
at more frequent intervals. On the other hand, in some cases 
of gastric catarrh with slow digestion it may be advantageous 
to limit the number of meals to two a day. 

Hygienic Treatment. — In a large number of cases sys- 
tematic exercise in the open air accomplishes much good. 
Anemic and neurasthenic patients, however, may require the 
" rest-cure." Hydrotherapy is often very serviceable. Mas- 
sage is also useful, especially when there is myasthenia. 
Change of scene, a sunny climate, good hours, and freedom 
from business worry and household cares often prove more 
beneficial than any other measure employed. 

Medicinal Treatment. — In cases of atonic dyspepsia and 
of mild gastric catarrh with subacidity the administration of a 
bitter — calumba, gentian, nux vomica, cinchona — some time 
before meals often proves efficacious. In many cases the 
bitter may be combined advantageously with an alkali (see p. 
175). Diluted hydrochloric acid, with or without pepsin, may 
also be of benefit when there is subacidity. It should be given 
after meals. 

When the stomach is unnaturally sensitive or when there is 
supersecretion, silver nitrate will be found a valuable remedy. 



DISEASES OF THE DIGESTIVE TRACT. $$? 

It may be given in pill form, with extract of hyoscyamus or 
of belladonna, half an hour before meals, or when this method 
of administration is not satisfactory, by means of the intragas- 
tric douche (see p. 372). Bismuth subnitrate in large doses 
before meals is also of service in such cases. 

In nervous dyspepsia short courses of strontium bromid are 
sometimes efficacious. When anemia is marked, an unirri- 
tating preparation of iron may be given with advantage. 

Systematic lavage (see p. 500) is of great value in certain 
cases, but it has been much abused. Its chief indications are 
retention of food with ferme?itation y excessive secretion of mucus, 
and excessive secretion of acid. When lavage cannot be tol- 
erated, the stomach may be cleansed by a glass of hot alkaline 
water slowly sipped a half-hour or more before breakfast. 
Motor insufficiency is often benefited by strychnin. Intragas- 
tric faradism and the intragastric spray (Einhorn) may also be 
recommended in cases of pronounced stagnation. 

Symptomatic Treatment. — Deficient Secretion. — When 
the digestive power is impaired owing to a deficiency of secre- 
tion, diluted hydrochloric acid with pepsin (seep. 182), taken 
shortly after meals, may be found useful. In many cases, 
however, better results are obtained from the administration 
of pancreatin with sodium bicarbonate. 

Hyperchlorhydria. — Severe pain occurring at the height of 
digestion and caused by hyperacidity is best treated by the 
administration of an alkali (sodium bicarbonate or magnesia) 
in large doses. Heartburn and pyrosis are also relieved by 
alkalis. 

Flatulence and fermentation are sometimes controlled by 
such antiseptic drugs as creosote, bismuth subsalicylate, bis- 
muth betanaphthol, and thymol. The following combination 
is often of value : 

R Creosoti, foss (2.0 c.c. ) ; 

Bismuthi betanaphthoiis, gr. c (6. 5 gm.) ; 

Strychninse sulphatis, gr. ss (0.03 gra.) ; 

Oleoresinge zingiberis, TT^v (0.3 c.c). M. 
Pone in capsulas No. xx. 
Sig. — One after meals. 

Vomiting usually yields to rest and proper diet. If trouble- 
some, sedatives like bismuth subnitrate, hydrocyanic acid, and 
silver nitrate may be employed. 

Constipation. — As far as possible constipation should be 
overcome by regulation of the diet, systematic exercise, and 
abdominal massage. Strong purgatives should be avoided. 



558 APPLIED THERAPEUTICS. 

A glass of water in the morning upon rising or in the evening 
before retiring often suffices in mild cases. If necessary, a 
small quantity of sodium phosphate or of the following arti- 
ficial Carlsbad salt may be added : 

R Sodii sulphatis, £x (40.0 gm. ) ; 

Sodii bicarbonatis, giv (16.0 gm.) ; 

Sodii chloridi, 2^ij (8.0 gm.). M. 

Sig. — A teaspoonful in a glass of water an hour before breakfast. 

One of the natural sulphated waters may often be used with 
advantage, especially when there is a tendency to excessive 
secretion of acid. Suppositories containing glycerin and ene- 
mata of warm water are harmless and generally effective. In 
some cases mild vegetable laxatives, like cascara sagrada and 
rhubarb, are required. The occasional use of calomel in small, 
frequently repeated doses sometimes serves a good purpose. 

GASTRALGIA. 

The hygienic and dietetic treatment described under Indi- 
gestion is applicable to gastralgia. Especially important is it 
to forbid the excessive use of tobacco, tea, coffee, and alcohol. 
When the attacks show a tendency to occur midway between 
meals, the administration of 3 or 4 ounces (90.0-120.0 c.c.) of 
milk with lime-water, two or three hours after meals, is often 
of service. 

Treatment of the Attack. — Stupes or hot compresses 
should be applied over the epigastrium. Internally, such 
remedies as chloroform (5-10 min. — 0.3-0.6 c.c), Hoffmann's 
anodyne (20-30 min. — 1.2-2.0 c.c), diluted hydrocyanic acid 
(2-3 min. — 0.1-0.2 ex.), and antipyrin frequently afford relief. 
The following combination will be found of value in many 
cases : 

R Acidi hydrocyanici diluti, TTlxxxv (2.0 c.c.); 

Antipy rinse, ^ij (8.0 gm.) ; 

Tincturse opii camphoratae, f %] (30.0 c.c.) ; 

Aquse chloroformi, q. s. ad f ^iij (90.0 c.c). M. 

Sig. — A dessertspoonful in hot water. 

If the pain be very severe, it will be necessary to resort to 
the hypodermic injection of morphin and atropin. 

Treatment. — The two most useful remedies are silver 
nitrate and arsenic. The former should always be selected 
when there is hyperesthesia of the mucous membrane or 
hyperchlorhydria. It may be combined with belladonna, as in 
the following formula : 



DISEASES OF THE DIGESTIVE TRACT. 559 

R Argenti nitratis, gr. v (0.3 gm.) ; 

Extracti belladonna, gr. iv (0.26 gm.) ; 

Mannae, q. s. 

Fiant pilulse No. xx. 
Sig. — One pill half an hour before meals. 

The best preparation of arsenic is Fowler's solution, which 
should be given after meals in increasing doses. 

Galvanism is sometimes of service ; the anode may be placed 
over the epigastrium, and the cathode over the dorsal spine. 
Very severe cases may demand a complete change of scene 
and air or a modified " rest-cure." 

Gastralgia depending upon anemia, locomotor ataxia, or 
malaria is to be treated, of course, on special principles. 

GASTRIC ULCER, 

Rest and appropriate diet are the most important factors in 
the treatment of gastric ulcer. The rest should be kept up for 
from six to twelve weeks, and for the first two or three weeks 
of this period the patient should be confined to bed. If hem- 
orrhage has recently occurred or if vomiting be urgent, it is 
advisable to withhold all food from the stomach for a few days 
and to nourish the patient by means of nutritive enemata. The 
following enema of Boas is usually well borne : 

& Milk, 250 grams ; 

Yolk of two eggs, 

Salt, 2 grams ; 

Claret, 15.0 cubic centimeters; 

• Baked flour, 15 grams. 
Use 1 to 3 in twenty-four hours. 

The following preparation suggested by Ewald is also use- 
ful : A tablespoonful of baked flour (dextrinized) is boiled with 
one-half of a glass of a 15 per cent, solution of glucose, and a 
wineglassful of claret is added. Two or three eggs, which 
have been beaten up with a tablespoonful of water and a pinch 
of salt, are stirred into the mixture after it has cooled suffi- 
ciently to prevent the coagulation of the albumin. The entire 
quantity should not measure more than \ pint (0.25 L.). 

After the pain and vomiting have sensibly abated, feeding by 
the mouth should be resumed. The diet should consist of 
milk, buttermilk, beef-juice, animal broths, egg-white, and thin 
pap. As soon as the gastric symptoms have completely dis- 
appeared, which will rarely be before the lapse of three or four 
weeks, the patient may be allowed such articles as soft-boiled 
eggs, scraped beef, boiled sweetbreads, the tender part of 
oysters, white meat of chicken, well-made gruel, and custard 
pudding. 



560 APPLIED THERAPEUTICS. 

Medicinal Treatment. — The most useful drugs are alka- 
lis, silver nitrate, and bismuth subnitrate. The alkalis are 
useful in overcoming the superacidity of the gastric juice. 
Sodium bicarbonate is one of the best ; it may be combined 
with magnesia or chalk, according as there is constipation or 
diarrhea. Artificial Carlsbad salt (see p. 558) is an excellent 
alkaline laxative ; of this a teaspoonful or more may be taken 
in half a pint of hot water before breakfast. Silver nitrate and 
bismuth subnitrate undoubtedly possess some value, although 
they probably exert no specific influence on the ulcer itself. 
The two drugs may be given alternately, each for a period of 
a week or ten days (see pages 372 and 375). 

Vomiting usually yields to complete rest, rectal feeding, and 
the administration of silver or bismuth. In some cases it may 
be necessary to use in addition a local sedative, like hydro- 
cyanic acid (see p. 160) or cocain. Morphin administered 
hypodermically is often very efficacious. 

Violent pain will also demand morphin, although the danger 
of inducing a habit must always be borne in mind. Exter- 
nally, stupes or sinapisms are sometimes useful. 

In the treatment of hematemesis absolute rest is essential. 
No food of any kind should be given by the mouth. An ice- 
bag should be applied over the stomach and morphin should 
be given hypodermically. The application of firm bandages 
to the four extremities may act favorably. Ergot and local 
astringents like tannic acid, iron sulphate, and lead acetate are 
of very doubtful utility. Ewald and Minkowski have recom- 
mended rinsing the stomach with ice-water as a last resort. 
Collapse following hemorrhage will call for diffusible stimu- 
lants, the external application of heat, and subcutaneous and 
rectal injections of warm saline solutions. 

Operative interference is rarely warranted unless the hemor- 
rhage be repeated. 

Surgical Treatment. — In all cases of perforation an opera- 
tion should be done at the earliest possible moment. The 
mortality in 123 cases operated on for perforation since 1896 
was 47.15 per cent. (Bidwell). In a series of 18 cases operated 
on within twelve hours after perforation, and reported since 
1896, the mortality was only 16.66 per cent. (Keen). When 
life is threatened by repeated hemorrhage, operation, in the 
interval between attacks (gastro-enterostomy or pyloroplasty) 
offers the best method of relief. Again, an operation (gastro- 
enterostomy, pyloroplasty, or partial gastrectomy) should be 
considered if the disease does not yield to medical treatment 
and the life of the patient is endangered by malnutrition. 



DISEASES OF THE DIGESTIVE TRACT. 56 1 



GASTRIC CANCER. 

Medicinal Treatment. — The medicinal treatment of gas- 
tric cancer is purely palliative. The chief indications are to 
maintain nutrition and to relieve distressing symptoms. In 
the early stages of the disease, when the pylorus is still free, 
a mixed diet of readily digested food is often well borne. 
Later, when there is retention, food should be selected which 
leaves but little residue in the stomach. Eggs, finely divided 
tender meats, sweet-bread, soft part of oysters, clear soups, 
calf's-foot jelly, and thin gruels are admissible. A small 
quantity of light wine with meals is sometimes very beneficial. 
Milk is often badly borne. If the stomach is unretentive re- 
course should be had to rectal feeding. 

Bitters — nux vomica, calumba, gentian — may often be em- 
ployed with advantage. Condurango (see p. 177) is an excel- 
lent stomachic, wholly lacking, however, in the specific prop- 
erties with which it was at one time credited. In many cases, 
but by no means invariably, hydrochloric acid is a useful 
adjuvant to the bitters. 

Lavage affords the very best means of relieving the distress- 
ing symptoms resulting from retention. Vomiting that is not 
dependent upon retention may be treated with such remedies 
as carbonated water, hydrocyanic acid, bismuth subnitrate, 
creasote, cerium oxalate, and chloroform. In obstinate cases 
rectal feeding may be required for a time. Acid eructations 
and flatulency are sometimes relieved by antacids and anti- 
septics, but in the majority of cases lavage is much more 
effective. 

The pain, if severe, will require codein or morphin. Milder 
attacks may be relieved by lavage, the administration of ant- 
acids or of sedatives, like carbolic acid, hydrocyanic acid, or 
chloroform, and by the external application of hot compresses 
or stupes. 

Constipation may be treated by simple enemata, glycerin 
suppositories, or by mild vegetable laxatives. 

Surgical Treatment. — Statistics of the surgical treatment 
of gastric cancer do not present a very favorable showing, 
although the mortality of the operative procedures is diminish- 
ing year by year. There are but two operations to be con- 
sidered — partial gastrectomy and gastro-enterostomy. The 
former is curative in its aim, the latter purely palliative. 

In 291 cases of resection of the pylorus or of a portion of 
the stomach recorded between 1890 and 1898, the mortality, 

36 



562 APPLIED THERAPEUTICS. 

according to Guinard, was about 35 per cent. Earlier inter- 
vention and improvement in technic has gradually lessened the 
mortality, and at present it is probably not more than 25 per 
cent. Unfortunately, very few patients have remained free from 
recurrence longer than three years after the operation. Wolfer 
cites 3 patients who lived over four years, 4 over five years, 
I over six years, and 2 over eight years. 

Gastro-enterostomy is preferable to gastrectomy in cases 
with extensive adhesions or marked glandular involvement. 
Moynihan has reported 35 cases with 5 deaths, and Robson 34 
cases with 3 deaths. When performed successfully, this opera- 
tion affords great relief and may prolong life several months, 
and, occasionally, even a year or two. 



DILATATION OF THE STOMACH. 

The treatment of dilatation of the stomach is medical and 
surgical. 

Medical treatment is frequently curative when there is 
no actual stenosis of the pylorus. The diet is of the first 
importance. Foods should be selected which are nutritious, 
which are not bulky, and which do not readily ferment. Ten- 
der meats, eggs, light cereals, fresh butter, cream, and toasted 
bread may usually be allowed. Milk is often badly borne, 
and in many cases liquids of all kinds must be somewhat re- 
stricted, but it is rarely necessary to resort to the dry diet of 
Schroth and other writers. In severe cases predigested meat 
preparations are often of service. P. Cohnheim has found 
olive oil useful when spasm of the pylorus is a factor. 

In the majority of cases it is best to limit the meals to three 
or four a day; occasionally, however, it will be found neces- 
sary to give the food in small quantities at frequent intervals. 
The time required for the stomach to empty itself should be 
ascertained in each case, and should be the guide in determin- 
ing the number of meals a day. 

To prevent retention, to control fermentation, and to cleanse 
the stomach no measure is so valuable as lavage (see p. 500). 

In the cases due to atony, massage, exercise in the open air, 
and hydrotherapy are valuable aids. A carefully adjusted 
abdominal bandage nearly always affords comfort and gives 
mechanical support to the stomach. Faradization of the 
stomach is useful in promoting muscular contraction. 



DISEASES OF THE DIGESTIVE TRACT 563 

Few drugs are of value. Nux vomica may often be given 
with advantage. When there is hypo-acidity, diluted hydro- 
chloric acid is indicated. Such remedies as creosote and the 
salicylic compounds are sometimes of benefit in checking fer- 
mentation, but the relief they afford is not to be compared to 
that obtained through systematic lavage. Constipation should 
be treated, as a rule, by simple enemata or by glycerin sup- 
positories. 

Surgical Treatment. — In the large majority of cases of 
non-obstructive dilatation medical treatment suffices. Occa- 
sionally, however, surgical intervention is demanded on account 
of persistent suffering and progressive emaciation. The oper- 
ation indicated in these cases is gastroplication. In 15 cases 
collected by Keen (1898) all the patients recovered but one. 

In cases of pyloric obstruction of a benign character an 
operation is indicated when it is impossible to maintain nutri- 
tion by proper medical treatment. As Loreta's digital divul- 
sion of the pylorus has been largely abandoned, owing to its 
high mortality (31.1 per cent), there may be said to be but two 
operations available — pyloroplasty and gastro-enterostomy. 
The mortality in 14 cases of pyloroplasty reported by Carle 
was 7 per cent, while Morison has reported 1 1 cases, and Mayo 
8 cases without a death. When performed by a surgeon hav- 
ing exceptional skill, gastro-enterostomy, in benign affections, 
yields a mortality of less than 8 per cent. The question of 
operative intervention in malignant stricture of the pylorus 
has already been considered (see p. 560). 



CHRONIC CONSTIPATION. 

In many cases chronic constipation can be successfully 
treated by attention to hygienic measures and by careful regu- 
lation of the diet without resorting to drugs. Not infrequently 
the normal activity of the bowels may be restored by repeated 
daily attempts at defecation at some special hour. Systematic 
exercise and cold bathing are of the greatest benefit. Abdom- 
inal massage, especially digital kneading in the direction of the 
colon, is often quite effectual. In persons with relaxed abdom- 
inal walls the wearing of a snugly-fitting binder will be found 
of service. 

Food should be selected which leaves considerable undi- 



564 APPLIED THERAPEUTICS. 

gested residue. Green vegetables, oatmeal, corn-meal, whole- 
wheat bread, and cooked fruits are available. Oils may often 
be given with advantage. Water-drinking should be encour- 
aged. In mild cases a glass of cold water taken in the morn- 
ing shortly after rising may suffice. 

When hygienic treatment proves insufficient, drugs will be 
required. Any underlying condition of which the constipation 
may be but a symptom should receive careful attention. Gen- 
eral tonics, like iron and strychnin, are often indicated. Min- 
eral waters, like Friedrichshall, Hunyadi Janos, or the milder 
Saratoga or Bedford waters, are very useful, but possess no 
special advantages over the saline laxatives (sodium phosphate, 
or Rochelle salt), when the latter are taken in small amounts 
well diluted. Enemata of soapy water or of glycerin, or 
suppositories of gluten, soap, or glycerin, often prove highly 
satisfactory. Vegetable cathartics are usually necessary in 
obstinate cases. The mild ones should always be tried first, 
and even with these considerable care should be exercised lest 
the patient comes to rely upon drugs to the exclusion of the 
hygienic and dietetic measures already indicated. Of the mild 
laxatives, cascara sagrada is one of the best ; from 10 to 30 
min. (0.6-2.0 c.c.) of the fluid extract, or a corresponding dose 
of an agreeable elixir, may be administered at bedtime and re- 
peated, if necessary, in the morning. In some cases a combi- 
nation of several laxatives acts better than any one singly. 
The drugs to be preferred for conjoint use are rhubarb, aloes, 
podophyllin, and euonymin. As adjuvants, nux vomica or 
physostigma may be added to overcome atony of the bowel, 
and belladonna or hyoscyamus to prevent griping. The most 
suitable combination must be determined in each case by ex- 
perience. A pill, like one of the following, will generally be 
found efficacious : 



R Resinae podophylli, 


gr. iv (0.26 gm.); 


Aloes purificatae, 


gr. xx-xl (1.3-2.6 gm. 


Extracti nucis vomicae, 




Extracti belladonnae, 


da gr. iv (0.26 gm.). M. 


Fiant pilulae No. xx. 




Sig. — One pill at bedtime. 





R Pulveris rhei, 

Extracti rhamni purshianae, ad gr. xxiv (1.5 gm.) ; 

Extracti euonymi, gr. xij (0.8 gm.) ; 

Extracti physostigmatis, 

Extracti belladonnse, da gr. iv (0.26 gm.). M, 

Fiant pilulae No. xxiv. 
Sig. — One pill at bedtime. 



DISEASES OF THE DIGESTIVE TRACT. 565 

R Aloini, gr. iv (0.26 gm.) ; 

Pulveris rhei, gr. xxxvj (2.3 gm.); 

Pulveris ipecacuanhae, gr. vj (0.4 gm.) ; 

Resinae podophylli, gr. iij (0.2 gm.) ; 

Extract! hyoscyami, gr. xij (0.8 gm.). M. 
Fiant pilulae No. xxiv. 
Sig. — One pill at bedtime. 

ACUTE DIARRHEA. 

Acute Diarrhea in Adults. — Rest in bed and the substi- 
tution of bland nourishment for the ordinary diet are all that 
is required in many cases. Boiled milk, milk and arrow-root, 
and mutton, veal, or chicken broth are suitable foods. If the 
patient is seen at the outset and there is reason to believe that 
irritant material is still present in the bowel, it is advisable to 
administer an unirritating purgative, such as castor oil, Epsom 
salts, or fractional doses of calomel. Occasionally a second 
dose of the purgative may be given with benefit. Externally, 
stupes or sinapisms are frequently efficacious. 

If there be much pain, opium should be administered. 
Dover's powder and paregoric are deservedly popular prepara- 
tions. If the diarrhea continue, mild astringents, like bismuth 
subnitrate and chalk, are indicated. They may be combined 
advantageously with an antiseptic, as in the following formulae : 

R Bismuth i subnitratis, £iij (12.0 gm.) ; 

Bismuthi subsalicylatis, gj (4.0 gm.). M. 

Fiant chartulse No. xij. 
Sig. — One powder every two or three hours. 

R Salolis, ^ss(2.ogm.); 

Bismuthi subnitratis, 

Cretae praeparatss, aa ^ij (8.0 gm.) ; 

Pulveris acacias, q. s. 

Aquae cinnamomi, q. s. ad fgiij (90.0 c.c). M. 

Sig. — A dessertspoonful every two or three hours. 

When opium is indicated, it is better to prescribe the drug 
separately, so that it may be discontinued more readily when 
no longer required. Preparations containing tannic acid are 
rarely needed, but when the discharges are very profuse and 
watery, small doses of tannalbin or of tannigen (see p. 356) 
may prove serviceable. Cases in which gastric indigestion is 
an important factor are often benefited by pancreatin in con- 
junction with bismuth subnitrate and an alkali. If the diar- 
rhea shows a tendency to become chronic, mineral astringents, 
like silver nitrate and lead acetate, with opium, in pill form, 
will be found effective. 

When there is reason to believe that the colon is especially 



566 APPLIED THERAPEUTICS. 

involved, local treatment is of the utmost value. Copious in- 
jections of warm water both cleanse the bowel and exert a 
soothing effect upon the irritated mucous membrane. Small 
enemata (1-2 oz. — 30.0-60.0 c.c.) of starch-water with lauda- 
num (5-10 min. — 0.3-0.6 c.c.) are very useful. In subacute 
colitis enemata containing silver nitrate (see p. 372) often prove 
efficacious. 

Treatment of Acute Diarrhea in Infants. — Preventive 
treatment is of the utmost importance. Improper food and 
faulty methods of feeding are the two prime factors in causing 
the disease. Fresh cows' milk containing a minimum number 
of bacteria to the cubic centimeter should form the basis of all 
food that is intended to replace healthy breast-milk. In sum- 
mer the milk should be received from the dairyman twice in 
the day, if possible, and should be placed immediately in a 
good refrigerator and kept there until such times as it is wanted. 
In very warm weather it may be necessary to resort to sterili- 
zation or pasteurization as a further means of preservation, but 
it must be remembered that neither of these processes can re- 
move from the milk any pre-existing impurities. The strength 
and quantity of the food and the number of meals per day 
must be carefully adapted to the infant's age and its digestive 
powers. As an additional precaution in extremely hot weather 
it may be advisable to dilute the milk a little more than usual 
in order to lessen the percentage of fats and proteids. 

Next to purity and freshness of the milk, it is important to 
insist upon absolute cleanliness of all the feeding apparatus. 
The nursing bottle and rubber nipple should be thoroughly 
washed after each meal. The child should have a daily morn- 
ing bath, and on very warm days it is advisable to give one or 
two tepid sponge baths (90 F. — 32 ° C.) in addition to the 
ordinary bath. In summer, if the weather be good, the child 
should pass most of the time in the open air, protected, of 
course, from the winds and the direct rays of the sun. 

The first indication in the treatment of the disease is to with- 
draw the milk at once, and to withhold it for several days or 
until the stools become quite natural. Indeed, in many cases 
it is well to suspend all nourishment for the first twenty-four 
hours, allowing nothing by the mouth but barley-water or 
plain boiled water. Subsequently, albumin-water, fresh beef- 
juice, veal broth, or a liquid peptone preparation may be given 
in lieu of milk. Milk feeding should always be resumed very 
gradually. Absolute rest in the recumbent position is essen- 
tial. Removal to the seashore or mountains is often of the 
greatest benefit. 



DISEASES OE THE DIGESTIVE TRACT. 567 

After the withdrawal of the milk, the next most important 
step in the treatment is the administration of a purgative like 
castor oil or calomel. Of these, calomel should be given the 
preference when the stomach is irritable. In many cases free 
purgation alone suffices to cleanse the bowel, but when the 
stools are offensive or there is marked toxemia enteroclysis 
should also be practised once or twice a day, according to the 
severity of the attack. In cholera infantum intestinal irrigation 
may be employed to meet several indications : to lower tem- 
perature, to combat collapse, to relieve the anhydremia, and to 
stimulate renal secretion (see p. 498). In choleraic forms of 
the disease lavage and hypodermoclysis are also of great value. 
In most cases of acute diarrhea it is necessary to follow the 
purge with a sedative astringent, like bismuth subnitrate or 
chalk. From 5-10 gr. (0.3-0.6 gm.) of one of these drugs 
may be given every two or three hours. Intestinal antiseptics 
(salol, bismuth salicylate, betanaphtol bismuth) are useful adju- 
vants. Some such combination as the following may be 
ordered with advantage : 

R Bismuthi subnitratis, ^ij-iv (8.0-16.0 gm.) ; 

Salolis, gr. xxiv (1.5 gm.) ; 

Misturse cretae, ffiij (90.0 c.c). M. 

Sig. — A teaspoonful every two hours. 

A more active astringent, like tannalbin or tannigen, may be 
given in addition to the bismuth subnitrate or chalk when the 
discharges are exceedingly profuse and watery. 

In ileocolitis intestinal irrigation may be followed by injections 
of I or 2 ounces (30.O-60.O c.c.) of a solution of silver nitrate 
(|- gr. to the ounce — 0.03 gm-30.0 c.c), of from \ to 1 ounce 
(15.0-30.0 c.c.) of a mixture of bismuth subnitrate (1 dram 
to the ounce — 4.0 gm-30.0 c.c), or of from 3 to 4 ounces 
(90.0-120.0 c.c.) of a solution of tannin (1 per cent.). If the 
injection containing silver nitrate excite pain, the bowel should 
be flushed with salt solution. 

Opium is often of the utmost value, but extreme caution 
must be exercised in its use. On the whole, it has undoubtedly 
caused more harm than good. In many cases there is abso- 
lutely no indication for it. It is called for when the diarrhea 
continues in spite of the thorough unloading of the bowel and 
the administration of mild astringents. One of the best prepa- 
rations is paregoric ; of this, from 3 to 5 minims (0.2-0.3 c.c) 
may be given every two, three, or four hours according to cir- 
cumstances. Opium should not be added to mixtures, but 
should be prescribed by itself. When the stomach is unreten- 



568 APPLIED THERAPEUTICS. 

tive, laudanum in doses of from I to 2 minims (0.06-0.1 c.c.) 
may be added to starch-water (J- ounce — 15.0 c.c.) and admin- 
istered by the rectum. In cholera infantum small doses of 
morphin (yfg- gr. — 0.0006 gm.) with atropin (-g-^- gr. — 
0.00008 gm.) may be given hypodermically. 

Stimulants are often required. Whisky and brandy are 
perhaps the best. From 10 to 20 minims (0.6-1.2 c.c.) of one 
or the other may be given in cold water every two, three, or 
four hours. When the stomach is unretentive, it will be neces- 
sary to administer stimulants hypodermically. Hypodermo- 
clysis also affords a valuable means of preventing exhaustion. 
In threatened collapse hot packs or hot baths may prove bene- 
ficial. 

Fever, according to its intensity, should be controlled by 
cold sponging, cold packs, or cool baths (85°~75° F. — 29.5 - 
24 C). Intestinal irrigation with cool water may also be used 
for its antipyretic effect. 

CHRONIC DIARRHEA. 

The first thing to do is to ascertain the cause and to remove 
this, if possible. The diet, clothing, habits, occupation, and 
mode of living of the patient should receive the most careful 
attention. No definite rules can be laid down in reference to 
the diet. Many patients do well upon an exclusive milk diet. 
Scraped beef, raw or underdone, is often well borne. In some 
cases it is an advantage to have the food peptonized. When 
the disease is not very severe and is confined for the most part 
to the colon, a selected mixed diet may be allowed. In such 
cases pulled bread or toast, tender beef or mutton, oysters, 
raw or boiled eggs, boiled rice, arrow-root, and plain cus- 
tard are available. Foods that are bulky and leave much resi- 
due are always inadmissible. 

Protection of the body against chilling is of vital importance. 
Woolens should be worn next to the skin. A snugly fitting 
abdominal bandage may be worn as an additional safeguard. 
Rest in bed is sometimes essential. The obstinate diarrhea 
occasionally encountered in hysterical women is often benefited 
by a modified rest cure. When the general nutrition is not too 
much impaired, a change of air and scene may prove very 
effectual. 

The medicinal treatment of chronic diarrhea is very un- 
satisfactory. Mineral astringents, especially bismuth subni- 
trate (30-40 gr. — 2.0-2.5 g m J> silver nitrate (J-J gr. — 0.016- 
0.03 gm.), copper sulphate (J-i gr. — 0.016-0.06 gm.), and lead 



DISEASES OF THE DIGESTIVE TRACT. 569 

acetate (1-3 gr. — 0.06-0.2 gm.), enjoy the most repute. These 
drugs should always be given a thorough trial, as even under 
the most favorable conditions improvement is slow in appear- 
ing. Intestinal antiseptics — salol, thymol, bismuth subsalic- 
ylate, creasote, betanaphthol-bismuth, and benzonaphthol — are 
useful adjuvants to astringents, especially when there is con- 
siderable intestinal fermentation. Opium in small amounts is 
often required, particularly in acute exacerbations. Wood has 
found the following tar-water mixture a most effective remedy 
in many cases : 

R Picis liquidae, f^iij (90.0 c.c.) ; 

Triturentur cum liquore calcis, 

Oviij (4.0 L. ), ad saturationem, 

et percolentur per prunum vir- 

ginianam, ^viij (250.0 gm.). M. 

Sig. — A wineglassful one to two hours after meals. 

In the diarrhea of hysterical women strontium bromid is 
sometimes of value. Arsenic (see p. 310) has been highly 
recommended in that form of diarrhea characterized by an 
uncontrollable desire to evacuate the bowel immediately after 
taking food. In malarial cases a cure is generally rapidly 
effected with quinin. When there is decided anemia, tincture 
of ferric chlorid will be found serviceable. In many cases it 
is a good plan to resort to intestinal irrigation from time to 
time or to administer a purgative (castor oil, Epsom salts, or 
calomel) occasionally to remove from the bowel scybalous 
masses or viscid mucus. 

When the disease is situated chiefly in the colon, local treat- 
ment is of the greatest service. Starch-water and laudanum 
enemata are sometimes useful. Generally, however, astringent 
injections are more successful. Irrigation of the bowel, two 
or three times a week, with a solution of silver nitrate (see p. 
372) is especially to be recommended. 

DYSENTERY. 

Rest in bed is imperative, even in chronic cases. In acute 
dysentery the diet should be liquid or semiliquid. Milk with 
lime-water, whey, milk-toast, animal broths, and egg-white may 
be given. Predigested foods are often very useful. In the 
chronic form of the disease it may be necessary to give a some- 
what more liberal diet in order to maintain nutrition. Soft- 
boiled eggs, pulled bread, boiled rice, oysters, and tender meats 
(chicken, mutton, and beef) may be allowed. The intestinal 
discharges should be disinfected immediately as in the case of 
typhoid fever. 



5/0 APPLIED THERAPEUTICS. 

An unirritating purgative (castor oil, Epsom salts, or calo- 
mel) is nearly always indicated at the onset. After the bowel 
has been thoroughly emptied, opium may be given to check 
peristalsis and to relieve the tormina and tenesmus. It is best 
given hypodermically in the form of morphin or by the bowel 
in the form of starch-water and laudanum injections or opium 
suppositories (J-i gr. — 0.03-0.06 gm.). Hot fomentations, tur- 
pentine stupes, or sinapisms to the abdomen also afford relief. 
Persistent tenesmus may sometimes be controlled by iodoform 
suppositories (2-5 gr. — 0.13-0.3 gm.). Wood speaks favorably 
of ice suppositories, inserted for a length of time, one after 
another. 

Some benefit may be derived from the administration of bis- 
muth subnitrate (20-30 gr. — 1. 3-2.0 gm.j by the mouth, com- 
bined with an antiseptic like salol or betanaphthol-bismuth. 
Sulphur is another remedy well worthy of trial in obstinate 
cases. Ten grains (0.65 gm.) should be given three or four 
times a day, combined with a small quantity of opium. In 
many cases the adynamia is so pronounced that stimulants 
must be used freely. In cases in which the typhoid state is 
well developed oil of turpentine, 5-10 minims 10.3-0.6 c.c.) in 
emulsion, often acts favorably. 

After the most acute symptoms have subsided intestinal irri- 
gation may be employed with the greatest benefit. The patient's 
hips should be elevated and the fluid should be introduced 
very gently and slowly by means of a fountain syringe. When 
the rectum is very irritable, it is advisable to inject a small 
quantity of cocain solution (4 per cent.) before introducing the 
irrigator. In acute dysentery normal salt solution at a tempera- 
ture of ioo°-i03° F. (38°-39.5° C.) may be employed for the 
irrigation. Weak solutions of boric acid (J dram to 1 quart — 
2.0 gm.-i.o L.) and of potassium permanganate (2—5 grains 
to 1 quart — o. 1 3-0.3 gm. to 1.0 L.) have also been recom- 
mended. Hare has used zinc sulphocarbolate (40 grains to I 
quart — 2.6 gm. to 1.0 L.) with very satisfactory results. In 
amebic dysentery warm injections of quinin (from 1 : 5000 to 
I : 1000) have been found very efficacious. In chronic dysen- 
tery weak solutions of silver nitrate (10-30 grains to 1 pint — 
0.6-2.0 gm. to 0.5 L.) are generally the most useful (see p. 

37 2 )- 

Three special methods of treatment merit consideration : 

that by ipecac, that by salines, and that by antibacterial serum. 

Many practitioners who have had much experience in the 

treatment of dysentery in India have borne testimony to the 

value of ipecac. At the onset it is customary to give a large 



DISEASES OF THE DIGESTIVE TRACT. 57 1 

dose (30 gr. — 2.0 gm.), and this usually induces vomiting. 
After vomiting has occurred the drug is administered in smaller 
doses (2-5 gr. — 0.13-0.3 gm.) at intervals of two hours. To 
insure the retention of the latter doses opium is generally given 
a short time in advance of the ipecac. A successful result is 
indicated by the appearance, usually within twelve hours, of a 
copious black stool. In the sporadic dysentery of temperate 
zones this treatment has not proved very satisfactory. 

Magnesium sulphate is another remedy which has been 
brought prominently forward within the last few years, espe- 
cially in India and other tropical countries. In 1900, Buchanan 
reported a series of 453 cases of dysentery treated by this drug 
in which there were but 5 deaths. A purgative dose is first 
administered, and after the bowel has been thoroughly emptied, 
smaller doses (1 dr. — 4.0 gm.) are given three or four times a 
day, preferably in combination with aromatic sulphuric acid, 
as in the following formula : 

R Magnesii sulphatis, ^iss (45.0 gm.) ; 

Acidi sulphurici aromatici, fgij (8.0 c.c); 

Aquae cinnamomi, q. s. ad f^vj (180.0 c.c). M. 

Sig. — Tablespoonful three or four times a day. 

The treatment should be continued for several days after the 
stools have ceased to be dysenteric. Unlike the ipecac treat- 
ment, this plan not infrequently gives good results in the acute 
dysentery met with in temperate regions. 

The discovery that one form of acute dysentery is caused by 
a special organism, the bacillus of Shiga, is sufficient ground 
for hope that a curative serum will be forthcoming. Indeed, 
Shiga claims to have reduced the mortality in a recent epi- 
demic in Japan from 37 to 8 per cent, by means of an antibac- 
terial serum. 

APPENDICITIS. 

There is a considerable diversity of opinion among physi- 
cians and surgeons as to the best method of treating appendi- 
citis. Some advise surgical intervention in all cases as soon as 
the diagnosis is made ; others, among whom are the greater 
number of representative surgeons, advocate a policy of intel- 
ligent discrimination and selection. 

The author is of the opinion that operation should be urged — 
(1) At once in all cases in which the onset is very severe, the 
symptoms indicating special severity being marked right-sided 
tenderness and rigidity, distention, and vomiting, with or with- 
out fever ; (2) in cases of moderate severity which manifest no 



572 APPLIED THERAPEUTICS. 

improvement after the lapse of forty-eight hours ; and (3) in 
cases in which the symptoms, after decided improvement, re- 
turn. On the contrary, operation is rarely required, at least 
during the attack — (1) In cases of a mild type, in which the 
pain is unaccompanied by rigidity, distention, nausea, or vom- 
iting ; and (2) in cases of moderate severity in which improve- 
ment is noticeable within forty-eight hours. Operation during 
the quiescent stage, when the element of danger is almost en- 
tirely removed, is to be recommended — (1) When an acute attack 
has been followed by persistent tumefaction and tenderness, 
intestinal disturbances, or impairment of the general health ; 
(2) when there have already been two attacks, even of moderate 
severity ; and (3) when mild attacks occur with such frequency 
as to induce disability. 

Medical Treatment. — The medical treatment of appendi- 
citis is Very simple. The patient should be kept in bed at 
absolute rest. The diet should be restricted to small quantities 
of bland liquids — milk, albumin-water, and broths. Purga- 
tives, as a rule, should be avoided, although there is usually 
no objection to administering a mild saline aperient at the onset 
of the attack. Constipation is best relieved by enemata of 
warm water. Locally, cold or heat may be applied, according 
to the sensations of the patient. Applications should not be 
used which affect the integrity of the skin, as they render sur- 
gical intervention more difficult should it subsequently be re- 
quired. If the pain be very severe, morphin may be adminis- 
tered hypodermically ; only the minimum amount necessary to 
afford a measure of relief is to be used, however, as by ob- 
scuring the symptoms the drug prevents an accurate study of 
the progress of the case. 

CATARRHAL HEPATITIS. 

Diet is of the first importance. Fatty, starchy, and saccha- 
rine foods should be avoided. Milk, buttermilk, broths, egg- 
albumen, lean meats, oysters, toast, pulled bread, and well- 
cooked cereals — wheat, rice, and oat-meal — are admissible. 
Water-drinking is distinctly beneficial. Alkaline mineral waters, 
like Vals, Vichy, and Hathorn, are frequently of service. If 
constipation resists the action of these waters, daily evacua- 
tions should be secured by means of sodium phosphate, Carls- 
bad salts, Rochelle salts, or a sulphated water, like Hunyadi 
Janos or Friedrichshall. 

Bismuth subnitrate and silver nitrate are often of value in 
relieving the primary gastroduodenal catarrh. Ammonium 
chlorid (10 gr. — 0.65 gm. — thrice daily, after meals) is also use- 



DISEASES OF THE DIGESTIVE TRACT. S73 

ful. In obstinate cases, nitrohydrochloric acid, as originally 
recommended by Scott, may prove beneficial. Daily irrigation 
of the colon with from i to 2 quarts (1.0-2.0 L.) of cold water, 
as advocated by Krull, is sometimes followed by improvement 
Intestinal fermentation and flatulence may yield to inspissated 
ox-gall or to an antiseptic like salol, bismuth salicylate, or 
betanaphthol-bismuth. Itching should be treated with tepid 
alkaline baths and lotions of carbolic acid, boric acid, or diluted 
hydrocyanic acid. Internally bromids, in full doses, may be 
tried when the pruritus is severe. 

CHOLELITHIASIS. 

Medical Treatment.— Gall-stones in the gall-bladder or 
in the biliary passages cannot be dissolved. Turpentine and 
ether (Durande's mixture), chloroform, sodium succinate, 
sodium choleate, sodium oleate, and a host of other drugs have 
been recommended with a view to their solvent effects, but 
they have been found wholly ineffectual. Attempts to accom- 
plish the extrusion of calculi by means of drugs have proved 
equally futile. Probably not more than 5 per cent, of those 
who have gall-stones suffer any inconvenience from their pres- 
ence (Kehr). When symptoms occur, they result, in the large 
majority of cases, from a coincident cholecystitis. As the latter 
is the chief factor in exciting the violent expulsive efforts which 
force the stones from the gall-bladder into the ducts, it is 
mainly responsible for the recurrent attacks of colic. As we 
have no solvents for gall-stones and no remedies capable of 
effecting their expulsion, our efforts must be directed to keep- 
ing the stones quiescent, and this can be accomplished only 
by allaying catarrhal inflammation of the gall-bladder and by 
guarding against its recurrence. 

Diet and hygiene are of the utmost importance. The food 
should be plain and readily digestible. Saccharine matters, fat 
meats, and highly seasoned dishes are undesirable. With the 
view of promoting a more continuous flow of bile it is often 
advantageous, when the gastric digestion is well maintained, to 
give the food in small quantities at comparatively short inter- 
vals. A light meal at bedtime has been especially recommended 
by Kehr. Frequent feeding may prove very harmful, how- 
ever, when there is slow digestion with atony of the stomach. 
Water-drinking between meals should be encouraged. 

Regular exercise in the open air, provided the symptoms are 
latent, is extremely beneficial. Constriction of the upper part 
of the abdomen by corsets or other articles of dress is to be 
rigidly avoided. The practice of manipulating the gall-bladder 



574 APPLIED THERAPEUTICS. 

for the purpose of expelling calculi, which has been advocated 
by some, cannot be too strongly condemned. 

Freedom from worry and mental effort, probably by con- 
ducing to good digestion, often exerts a marked salutary effect. 

Digestive disturbances should receive appropriate treatment. 
Among drugs, alkalis and alkaline mineral waters are undoubt- 
edly efficacious. Sodium bicarbonate or sodium phosphate 
may be taken well diluted in the morning an hour before break- 
fast and also between meals. If there be decided constipation, 
a small quantity of Rochelle salt or sodium sulphate may be 
added to each potation. The natural mineral waters, notably 
those of Carlsbad and Vichy, have acquired a high reputation. 
When there is a tendency to so-called bilious attacks, an oc- 
casional course of calomel in fractional doses will be found of 
benefit. In similar cases irrigation of the bowel, once or twice 
a week, with from I to 2 quarts (1.0-2.0 L.) of cool water is 
also very useful. 

Finally, when there are no evidences of active inflammation 
in the gall-bladder and the patient's circumstances will permit, 
we may recommend a course of treatment at Carlsbad, Vichy, 
or Contrexeville, with some degree of confidence. An extended 
visit to one of these resorts is often followed by considerable 
improvement, and in rare cases by permanent relief. The 
benefit from a stay at one of these spas probably depends more 
upon change of air and scene, genial surroundings, regular 
hours, and freedom from worry than upon the waters them- 
selves. 

Hepatic Colic. — When the pain is violent it will be necessary 
to give morphin and atropin hypodermically at short intervals. 
As the opium habit is readily formed in these cases, it need 
scarcely be added that great caution should be exercised in the 
use of the drug. Agonizing pain often yields very promptly 
to a few whiffs of chloroform. In the mild but rather persistent 
attacks a few doses of antipyrin in hot water may suffice. The 
external application of heat is very useful. Hot poultices or 
fomentations may be applied to the region of the liver, or, when 
circumstances permit, the patient may be kept in a hot bath. 
Exceptionally, an ice-bag affords more relief than any of the 
hot applications. When vomiting is urgent, carbonated water, 
cracked ice, or small quantities of champagne may be given. 
In threatened collapse diffusible stimulants are needed. 

Acute Obstruction of the Common Duct. — The measures best 
suited for promoting the advance of the stone into the bowel 
are rest, regulation of diet, the free use of alkaline mineral 
waters, the occasional exhibition of saline laxatives, and the 



DISEASES OF THE DIGESTIVE TRACT 575 

application of heat to the hypochondriac region. Olive oil 
(see p. 465) has been recommended as a special remedy, but it 
is of doubtful efficacy. As the sequelae of impaction of the 
common duct are so numerous and so grave, surgical aid 
should be invoked if the obstruction is not removed under 
medical treatment within a period of two or three weeks. 

Surgical Treatment. — Surgical intervention is called for — 
(1) When, despite medical treatment, attacks of colic occur so 
frequently and are of such severity as to cause disability or 
make the addiction to morphin a likelihood ; (2) in persistent 
obstruction of the common duct ; (3) in hydrops of the gall- 
bladder due to impaction or stricture of the cystic duct ; and 
(4) in suppurative inflammation of the gall-bladder or gall- 
ducts. 

In the hands of experienced operators the mortality of 
cholecystotomy in uncomplicated cases is very low, certainly 
not more than I or 2 per cent. The mortality of choledochot - 
omyis higher, although in Kehr'slast 137 cases it was only 6.5 
per cent, and in a continuous series of 80 operations performed 
by Mayo Robson, it was less than 4 per cent. 

After operation medical treatment should be continued on 
the lines already laid down for the management of cholelithi- 
asis that is more or less latent, with the view of preventing the 
further formation of stones. 

CIRRHOSIS OF THE LIVER. 

As cirrhosis of the liver is almost invariably associated with 
congestion of the stomach and gastric catarrh, these conditions 
are the first to demand attention. A diet of bland, readily 
digestible food is indicated. Alcohol should be forbidden. 
Tea, coffee, fatty matters, and highly spiced or seasoned dishes 
are inadmissible. Milk, eggs, oysters, sweetbread, tender 
meats, and well-cooked cereals may usually be allowed. In 
advanced cases an exclusive milk diet is advisable. As in 
simple gastric catarrh, such drugs as silver nitrate and bismuth 
subnitrate are sometimes of service. Lavage of the stomach 
should not be practised for fear of wounding the varicose veins 
at the lower end of the esophagus. Measures which promote 
the action of the skin and kidneys should not be neglected. 

Portal congestion is best relieved by saline aperients and the 
occasional use of a mild mercurial. Mineral waters, such as 
those of Vichy, Carlsbad, Saratoga, Hunyadi Janos, and Fried- 
richshall, taken hot an hour before meals, often have an excel- 
lent effect. 



576 APPLIED THERAPEUTICS. 

Potassium iodid has been largely employed with the hope 
that it might favor the absorption of the overgrown connective 
tissue. While it is apparently useless in the absence of syph- 
ilis, in syphilitic cases it may prove very beneficial. 

Ascites. — Effusion that is only moderate in amount can 
sometimes be removed by the administration of cathartics and 
diuretics. A concentrated solution of Epsom salts (-§— I oz. — 
15.0-30.0 gm.), taken in the morning before breakfast, is usually 
the most efficient purgative. Occasionally it may be desirable 
to substitute compound jalap powder or elaterium. The 
diuretics of approved value are potassium acetate or bitartrate, 
digitalis, and squills. The combination of blue-mass, digitalis, 
and squills, known as Niemeyer's pill (see p. 52), has a well- 
deserved reputation. Murchison and Fagge advocated resin 
of copaiba (15 gr. — 1.0 gm., daily), but it often disturbs the 
stomach. The use of drugs should not be persisted in ; if the 
ascites does not diminish in the course of a few days, it is far 
better to resort to paracentesis. The operation is readily per- 
formed, and if done under antiseptic precautions, is attended 
with but very slight risk. It not only affords speedy relief, 
but, by removing the pressure from the abdominal veins, it 
also assists the action of diuretics. Occasionally, after one or 
two tappings, the fluid does not return for a long period — per- 
haps several months or even years ; generally, however, the 
abdomen quickly refills, so that frequent repetition of the opera- 
tion becomes necessary. 

The operation of paracentesis abdominis is performed as fol- 
lows : The bladder having been emptied, the patient is placed 
in a semirecumbent position, and a spot in the median line 
midway between the umbilicus and the symphysis pubis is 
anesthetized by means of a block of ice sprinkled with salt. 
A stout trocar is now introduced with a quick thrust into the 
abdominal cavity, a rubber tube is attached to the cannula for 
the purpose of conveying the fluid into a pail placed below 
the patient's bed, and the trocar is then withdrawn. While 
the fluid is escaping a many-tailed bandage is adjusted to the 
abdomen and gradually tightened. The application of such a 
binder should never be omitted. It gives support to the 
relaxed abdominal walls, and tends to prevent syncope and 
hematemesis. When the fluid ceases to flow, the cannula is 
removed, and the opening sealed with an antiseptic pad and a 
few strips of adhesive plaster. 

Surgical Treatment. — Talma's operation (suture of the 
omentum to the margin of an abdominal incision, and irritation 
of the peritoneal surface of the liver and spleen), or one of its 



DISEASES OF THE RESPIRATORY SYSTEM. 577 

modifications, has proved of some benefit in a limited number 
of cases of liver cirrhosis with ascites. The object of the 
operation is to establish a compensatory circulation by making 
accidental adhesions and thus increasing the anastomoses 
between the vessels of the portal system and those of the 
systemic circulation. In 227 cases collected by Sinclair White 
(November, 1906) death from the operation occurred in 33 
per cent, failure in 15 per cent, improvement in 13 per cent., 
and symptomatic cure in 37.3 per cent. The duration of the 
cure at the date of publication was between one and two years 
in 7 cases, between two and three years in 17 cases, and over 
three years in 5 cases. The operation is contraindicated when 
cardiac or renal disease coexists. 

DISEASES OF THE RESPIRATORY SYSTEM. 

ACUTE RHINITIS. 

In mild attacks little treatment is required. If the constitu- 
tional symptoms be severe, it is advisable for the patient to 
remain in his room, or even in his bed. When the patient is 
seen at the outset and is willing to remain indoors for twenty- 
four hours, a hot foot-bath, with a full dose of Dover's pow- 
der, followed in the morning by a Seidlitz powder or another 
saline aperient, often gives excellent results. When the patient 
is fully able to go about, the following capsules will usually 
afford considerable relief: 

Be Pulveris camphorae, gr. yj (0.4 gm,) ; 

Extracti belladonna, 
Codeinae sulphatis, aa gr. iss (0.1 gm.); 

Cinchoninae sulphatis, gr. xij (0.8 gm.). M. 

Pone in capsulas No. xij. 
Sig. — One every two or three hours. 

I/OCal treatment is very useful. In the early stage, when 
there is marked swelling of the mucous membrane, the appli- 
cation of cocain (2-4 per cent, solution) is sometimes exceed- 
ingly efficacious. If, however, no lasting effect is secured after 
three or four trials, its use should be discontinued. Warm 
Dobell's solution (see p. 172) or warm distilled extract of 
witch-hazel (diluted with 1 part of water), used as a spray at 
intervals, and followed in a few minutes by an oily application 
like the following, generally renders satisfactory service : 

R Mentbolis, gr. iij (0.2 gm.) ; 

Olei pini pumilionis, tit v (0.3 c.c.) ; 

Petrolati liquidi, q. s. ad f^j (30.0 c.c). M. 
37 



578 APPLIED THERAPEUTICS. 

Among numerous vapor-inhalations recommended for their 
soothing effect the following are worthy of mention : Com- 
pound tincture of benzoin, I dram (4.0 c.c), and hot water, I 
pint (0.56 L.); chloroform, 1 dram (4.0 c.cj, and hot water, 1 
pint (0.5 L.); iodin, 1 or 2 grains (0.06-0.13 gm.), and ether, 1 
ounce (30.0 c.c.) ; camphor, 1 dram (4.0 gm.), and hot water, 4 
ounces (120.0 c.c). 

CHRONIC RHINITIS. 

The treatment of chronic rhinitis is both general and local. 
It is highly important to ascertain the existence of any consti- 
tutional vice and to remove this if possible. Attention to 
hygienic conditions is most essential. Fresh air, out-door 
exercise, and frequent bathing, followed by friction of the skin, 
are to be insisted upon. Tonics, especially strychnin and cod- 
liver oil, are aften required. 

When the disease is not far advanced, much can be accom- 
plished by keeping the nasal passages thoroughly clean. For 
this purpose detergent alkaline fluids may be applied by means 
of a coarse spray or the nasal douche-cup. A large number 
of combinations have been suggested, of which Dobell's solu- 
tion (see p. 172) and the following are good examples : 

R Sodii bicarbonatis, 

Sodii boratis, aa gr. xxx (2.0 gm.) ; 

Sodii chloridi, gr. iij (0.2 gm.) ; 
Thymolis, 

Mentholis, aa gr. ss (0.03 gm.); 

Olei gaultheriae, TTLij (0.12 c.c); 

Glycerini, f ^ij (8.0 c.c.) ; 

Alcoholis, f^ss (2.0 c.c.) ; 
Aquae, q. s. ad f § viij (240.0 c.c). M. 

In the early stage, when the redundant tissue is not very 
dense, local remedies of an astringent or alterative character 
are often very efficacious. The following applications are in 
common use : A mixture of iodin and glycerin containing 6 
grains (0.4 gm.) of iodin, 12 grains (0.8 gm.) of potassium 
iodid, and 1 ounce (30.0 c.c.) each of glycerin and water; 
aqueous solution of ichthyol (20-40 per cent.) ; solution of 
zinc sulphocarbolate (2-5 per cent.); solution of resorcin (10 
per cent); and solution of silver nitrate (1-2 per cent). 

When the hypertrophic process has progressed so far that 
these simple measures prove ineffective, a more energetic treat- 
ment is demanded. The obstruction must be removed by 
means of caustics (chromic acid, trichloracetic acid, and acetic 
acid), the galvanocautery, or the snare, the proper use of 
which usually requires the services of a skilled specialist. 



DISEASES OF THE RESPIRATORY SYSTEM. 579 

Atrophic Rhinitis (Osena). — Improvement in the gen- 
eral health by the aid of fresh air, good food, and of such 
remedies as cod-liver oil, iron, arsenic, and strychnin is often 
requisite. If any syphilitic taint is suspected, potassium iodid 
and mercury should have a fair trial. Subcutaneous injections 
of antidiphtheritic serum have been used in a number of in- 
stances with alleged good results, this treatment having been 
tried in consequence of the assertion made by Belfanti and 
Delia Vedova, and confirmed by other observers, that a bacillus 
identical with the bacillus of diphtheria is the cause of ozena. 

The first requisite of local treatment is thorough cleanliness 
of the nasal passages, and to secure this the patient should be 
directed to spray the nose two or three times a day with 
Dobell's solution or some other mild detergent fluid. When 
the crusts are difficult to remove, they may be softened by 
pledgets of cotton soaked in a solution of hydrogen dioxid. 
After the nares have been cleansed, an oily solution like the 
following may be used to moisten and protect the parts : 

R Mentholis, gr. xx (1.3 gm.) ; 

Thymolis, gr. vj (0.4 gm.) ; 

Eucalyptolis, TT[xx (1.2 c.c.) ; 

Petrolati liquidi, fgvj (180.0 c.c.). M. 

Among the many local remedies which have been employed 
for their stimulant effects ichthyol is perhaps the best (see p. 
335). When there is much secretion, insufflations of zinc 
stearate (75 per cent, with boric acid), as recommended by 
C. C. Rice, are sometimes useful. 

Interstitial electrolysis has been used by some observers 
with considerable success. The modus operandi of this method 
of treatment is as follows : The nasal fossae having been cleansed 
and anesthesia having been produced by means of a 10 per cent, 
solution of cocain, a copper needle attached to the positive 
pole is introduced beneath the mucous membrane of the 
middle turbinated body, and a platinum needle attached to the 
negative pole is introduced into the lower part of the septum 
or into the outer wall of the inferior meatus of the same nos- 
tril. The intensity of the current employed has varied from 
6 to 1 5 milliamperes, and the duration of the sittings from ten 
to fifteen minutes. 

For destroying the offensive odor a large number of drugs 
have been suggested, of which the following may be mentioned : 
Citric acid (see p. 469), formalin (1 : 1000 to 1 : 500), Labar- 
raque's solution (1 : 30), potassium permanganate (2 grains to 
the ounce — 0.13 gm-30.0 c.c), and creolin (1 : 100). 



580 APPLIED THERAPEUTICS. 



ACUTE LARYNGITIS. 

In severe cases the patient should be confined to bed, and 
the temperature of the room kept uniformly at 70°-72° F. 
(2i°-22° C). The air should be rendered moist by means of 
steam. A hot foot-bath at the onset is often beneficial. The 
use of the voice should be avoided as much as possible. The 
external application to the throat of cold compresses or of an 
ice-bag is of service. In grave forms of the disease it may be 
advisable to apply a few leeches to the upper part of the 
sternum. 

Warm inhalations afford considerable relief. A dram (4.0 
c.c.) of compound tincture of benzoin, half a dram (2.0 c.c.) of 
oil of turpentine, or half a dram (2.0 c.c.) of oil of cubebs may 
be added to a pint (0.5 L.) of boiling water and the fumes in- 
haled. For want of a special apparatus for the administration 
of these inhalations steam may be collected and conducted by 
means of an ordinary tin funnel which has been inverted over 
a bowl containing the medicated hot water. In vaporizing 
oily substances it is advisable to mix them first with magne- 
sium carbonate in order to aid their suspension in the water. 

In the early stage direct local applications are rarely re- 
quired ; later in the disease, however, the application of astrin- 
gents by means of the atomizer often proves useful. Alum, 
5-10 gr. (0.3-0.6 gm.) to the ounce (30.0 c.c); silver nitrate 
(1-2 per cent, solution) and zinc sulphate, 2-3 gr. (0.13-0.2 
gm.) to the ounce (30.0 c.c), often give satisfactory results 
when used in this manner. 

Internal medication may do much good. At the onset of 
the disease it is usually advisable to administer a saline purge. 
If the cough be troublesome, a sedative, like Dover's powder, 
codein, or heroin, may be given in conjunction with a mild 
expectorant, such as ipecac, potassium citrate, or ammonium 
chlorid. 

In acute edematous laryngitis, when the swelling does not 
yield promptly to local bloodletting, the external application 
of ice, astringent sprays, scarification of the mucous mem- 
brane, and active catharsis, tracheotomy should be performed 
without delay. 

Spasmodic Croup. — The indications are to arrest the 
paroxysms and to prevent their recurrence. When the par- 
oxysms are severe, the child may be placed in a warm bath 
(100 F. — 38 C.) for ten or fifteen minutes, or an emetic (ipecac 
or alum) may be given instead. Occasionally the dyspnea is so 
intense as to demand the inhalation of a few drops of chloro- 



DISEASES OF THE RESPIRATORY SYSTEM. 58 1 

form or amyl nitrite. Mild attacks usually yield to the appli- 
cation, over the larynx, of a sponge wrung out of hot water. 

The remedial measures which have been advocated for 
simple laryngitis are also of service in preventing attacks of 
pseudo-croup. Such a combination as the following will 
generally be found useful: 

]£ Tincturae aconiti, Tt\, v j (0.4 c.c.) ; 

Vini ipecacuanhae, f 3J (4.0 c.c.) ; 

Potassii bromidi, gss (2.0 gm.) ; 

Potassii citratis, 3J (4.0 gm.) ; 

Syrupi tolutani, f 3J (30.0 c.c.) ; 

Aquae, q. s. ad f^ij (60.0 c.c). M. 
Sig. — A teaspoonful every two or three hours for a child of eighteen months. 



CHRONIC LARYNGITIS. 

It is highly important to determine in each case the under- 
lying cause of the local irritation, and to remove this if possi- 
ble. Injurious habits, such as the excessive use of tobacco or 
alcohol, must be corrected. The diet, exercise, bathing, and 
clothing must be carefully regulated. While it is essential 
that the body should be warmly clad, the practice of wearing 
thick scarfs about the neck as a means of protection from cold 
should be condemned. Daily sponging the neck and chest 
with cool water is a far better way of guarding against recur- 
rent attacks of inflammation. In some cases a change of 
occupation is imperative. Rest of the voice is always indi- 
cated. Not infrequently improper or excessive use of the 
voice is the main etiologic factor, and when this is the case 
permanent relief can be secured only by the correction of the 
error. As in a large group of cases a morbid process in the 
nasopharyngeal passages is the sole cause of the laryngeal 
irritation, it follows that the removal of this primary disease 
must often be the fundamental principle in the treatment. 
Any constitutional disease, such as rheumatism or gout, or any 
derangement of the digestion or circulation that may be pres- 
ent should receive careful attention. Change of scene and 
climate is often of the greatest benefit, a warm, dry climate 
being especially favorable to the condition. 

In many cases of chronic laryngitis tonics, like iron, strych- 
nin, and cod-liver oil, are efficacious. Even when there is no 
evidence of syphilis, potassium iodid in small doses is sometimes 
useful, especially when there is a great lack of secretion with 
a tendency to the formation of crusts. Expectorants have 
little, if any, effect upon the chronic process, but often prove 
serviceable in acute exacerbations. 



582 APPLIED THERAPEUTICS. 

Local treatment is of prime importance. Remedies are 
best applied by means of sprays or a camel's-hair brush or 
cotton swab. Lozenges are also of benefit in certain condi- 
tions. Vapor inhalations and insufflations of dry powders are 
not so satisfactory. Thorough cleanliness, not only of the 
larynx itself, but also of the nose and pharynx, is always 
requisite. This is best secured by spraying the parts at fre- 
quent intervals with a mild alkaline solution. If there be 
deficient secretion, one of the following solutions may be em- 
ployed as a spray after the mucous membrane has been 
cleansed : Sodium chlorid, 5 gr. (0.3 gm.) to the ounce (30.0 
c.c.) ; potassium chlorate, 5 gr. (0.3 gm.) to the ounce (30.0 
c.c.) ; ammonium chlorid, 5 gr. (0.3 gm.) to the ounce (30.0 
c.c.) ; or potassium iodid, 5 gr. (0.3 gm.) to the ounce (30.0 
c.c). Lozenges containing 1 or 2 gr. (0.6-0.13 gm.) of 
ammonium chlorid may also afford relief, especially if the 
pharynx be much affected. When there is excessive secre- 
tion, astringent sprays are indicated, and one of the following 
may be selected : Alum, 3-5 gr. (0.2-0.3 g m -) to tne ounce 
(30.0 c.c); zinc acetate, 3-5 gr. (0.2-0.3 gm.) to the ounce 
(30.0 c.c); zinc sulphocarbolate, 2-3 gr. (0.13-0.2 gm.) to the 
ounce (30.0 c.c) ; or lead acetate, 1-3 gr. (0.06-0.2 gm.) to 
the ounce (30.0 c.c). When more active astringents are re- 
quired, they should be applied directly to the larynx by 
means of a cotton swab or camel's-hair brush. Thus, benefit 
may be derived from a solution of tannin, 10 gr. (0.6 gm.) to 
the ounce (30.0 c.c.) of glycerin, or from a solution of silver 
nitrate, 5-10 gr. (0.3-0.6 gm.) to the ounce (30.0 c.c.) of 
water. Actual abrasions may be touched with a strong solu- 
tion of silver nitrate, 40-60 gr. (2.6—4.0 gm.) to the ounce 
(30.0 c.c). When there is scab-formation, a 20 per cent, solu- 
tion of ichthyol often proves useful. Large varicose vessels 
should be cauterized (chromic acid) under cocain anesthesia. 

Tuberculous laryngitis. — Hygienic, climatic, dietetic, 
and general medicinal treatment should be that of pulmonary 
tuberculosis (see p. 592). In the early stage medicated in- 
halations and sprays are of benefit. Such remedies as crea- 
sote, terebene, compound tincture of benzoin, and eucalyptol 
may be used in a respirator or inhaled from the surface of 
boiling water. As a rule, sprays are more satisfactory. After 
the mucous membrane has been thoroughly cleansed with an 
alkaline detergent spray, one of the following sprays may be 
used: Corrosive sublimate (1 : 5000 to 1 14000), resorcin (1-2 
per cent.), formalin (1 : 1000), or menthol (1-2 per cent). 

In tuberculous ulceration the treatment may be radical or 



DISEASES OF THE RESPIRATORY SYSTEM. 583 

palliative. Unfortunately, the latter is the only form of treat- 
ment that is applicable in the large majority of cases. When, 
however, the disease in the lung is not far advanced and the 
ulceration in the larynx is circumscribed and readily accessi- 
ble, the thorough removal of the diseased tissue may be 
attempted. The most approved method of radical treatment 
consists in the rubbing-in of lactic acid after the ulcer has 
been thoroughly cureted. If the ulcer be quite superficial, 
the curetment may be omitted. The parts must be carefully 
anesthetized with cocain (20 per cent, solution), and the acid 
applied in the proportion of 30, 50, or 75 per cent, solution, or 
even stronger, according to the effects. Ichthyol (undiluted) 
and guaiacol (undiluted) have been used in some cases instead 
of lactic acid. 

When the ulceration is more diffuse and is associated with 
considerable infiltration, better results may be obtained from 
one of the following applications : Carbolic acid, J— I dram 
(2.0-4.0 c.c.) to the ounce (30.0 c.c.) of glycerin ; tannin, 1 
dram (4.0 gm.) to the ounce (30.0 c.c.) of glycerin ; formalin 
(1-10 per cent, in glycerin); or chromic acid (2-3 per cent.). 

In the advanced stages of the disease only sedative applica- 
tions to relieve pain and dysphagia are justifiable. Among 
the agents most generally useful as insufflations may be men- 
tioned orthoform, iodoform, cocain, and morphin. Semon 
recommends iodoform (1 gr. — 0.06 gm.), boric acid (1 gr. — 
0.06 gm.), and morphin sulphate (^ gr. — 0.0 1 gm.). Fasano 
speaks highly of the following combination : Thiocol, 1 ; co- 
cain, 2 ; boric acid, 10. A 5-10 per cent, solution of menthol 
in liquid petrolatum used as a spray often affords much relief. 
Intratracheal injections have also been recommended. Vacher 
has had excellent results from injections of 30 minims (2.0 c.c.) 
of the following : Guaiacol, 5 parts ; eucalyptol, 2 parts ; men- 
thol, 1 part ; and saturated solution of iodoform in ether, 100 
parts. When dysphagia is very severe, it may be well to 
apply cocain to the larynx before eating, using a 2-4 per cent, 
solution as a spray or a 5-10 per cent, solution as a direct 
application. When deglutition is extremely painful, Wolfen- 
den suggests that the patient take liquid food while lying 
prone, the head hanging over the edge of a couch, and the 
nourishment being sucked through rubber tubing from a 
bowl on the floor. 

Syphilitic I^aryngitis. — Constitutional treatment with 
iodids and mercurials is of the first importance. Local clean- 
liness should be secured by thorough spraying with some 
alkaline antiseptic solution. Ulcers may be touched with 



584 APPLIED THERAPEUTICS. 

silver nitrate (melted on a silver probe), acid nitrate of mer- 
cury (1 to 5 parts of water), or chromic acid (1 to 8 parts of 
water). Insufflations of iodoform are also useful. Cicatricial 
stenosis may call for gradual dilatation or even tracheotomy. 

ACUTE BRONCHITIS. 

If the patient be weak or old, he should be confined to 
his room or even to bed; the atmosphere of the room should 
be kept warm and moist. If the patient be seen at the outset, 
it is useful to promote free diaphoresis, and this may be accom- 
plished by means of a hot foot-bath, with hot drinks and a full 
dose of Dover's powder. Warm inhalations, such as have 
been suggested in acute laryngitis (see p. 580), are also of 
service. Counterirritation to the chest in the form of sina- 
pisms or stupes is very beneficial. When there is much 
dyspnea, as there frequently is when acute bronchitis compli- 
cates emphysema, the application of dry cups, or even of a 
few wet cups, to the chest often has a marked salutary effect. 
The food should be simple and readily digestible, and the 
bowels should be kept regularly open by the aid of mild 
aperients. 

Distressing dry cough is usually best controlled by one of 
the opium derivatives — codein or heroin- — and fever by aconite 
with spirit of nitrous ether or by small doses of phenacetin. 
When for any reason opium is objectionable, hyoscyamus, 
spirit of chloroform, sodium bromid, or diluted hydrocyanic 
acid may be used instead. When the cough remains persist- 
ently dry sedative expectorants may be given to favor secre- 
tion. For this purpose potassium citrate, ipecac, apomorphin, 
and antimony are extensively employed. The combination 
of potassium citrate and ipecac given on page 271 is especially 
useful in this stage of the disease. In young, robust persons 
antimony is decidedly efficacious, and may be prescribed 
according to the formula suggested on page 272. 

When the bronchial secretion becomes more abundant, stim- 
ulant expectorants are indicated. Ammonium chlorid is one 
of the most reliable members of this class ; it may be pre- 
scribed in some simple vehicle, like brown mixture, or with 
squill, as in the formula given on page 276. Expectorants of 
an oily nature, such as terebene, oil of eucalyptus, oil of 
santal, and oil of copaiba are also very efficacious, but more 
liable than the ammonium salt to derange digestion. Such a 
combination as the following is often very serviceable when 
the catarrh tends to become subacute : 



DISEASES OF THE RESPIRATORY SYSTEM. 585 

Be Terebeni, 

Olei eucalypti, aa f £ss (2.0 c.c.) ; 

Strychninae sulphatis, gr. £ (0.02 gm.) ; 

Codeinae sulphatis, gr. ii-iij (0.13-0.2 gm). M. 

Pone in capsulas No. xij. 
Sig. — One every four hours. 

When the expectoration is purulent and heavy, a creasote 
derivative, like guaiacol carbonate, may be used with great 
advantage (for formula, see p. 287). 

In the aged and infirm alcoholic stimulants are often re- 
quired to combat general adynamia. Strychnin is a most 
valuable adjunct to the expectorants when there are indica- 
tions that the heart is becoming strained by the violent parox- 
ysms of cough. Should there be evidence of pronounced 
cardiac failure, it will be necessary to employ digitalis. 

Such tonics as cod-liver oil, iodid of iron, quinin, and arsenic 
are often useful during convalescence from severe and pro- 
longed attacks. Much benefit will also be obtained from 
suitable change of climate. 

CHRONIC BRONCHITIS. 

To meet with any measure of success, treatment must be 
directed largely toward the prevention of recurrent attacks, and 
the removal, if possible, of the underlying cause. Indiscrimi- 
nate routine treatment is to be rigidly avoided. Change of 
climate, especially in winter, is most beneficial, and should be 
urged if the circumstances of the patient will permit. When 
there is much bronchial secretion, a dry, warm climate, such as 
that of New Mexico or Southern California, in this country, 
and that of Egypt or the Riviera abroad, is generally to be 
recommended, whereas if there be little expectoration, a moist 
warm climate, such as that of Florida, the West Indies, Ma- 
deira, Pau, or Algiers, is preferable. When patients are unable 
to avail themselves of the benefits to be derived from a suitable 
climate, they should remain indoors as much as possible in bad 
weather, and take every precaution against exposure. Flannel 
should at all times be worn next to the skin, the feet should be 
kept perfectly dry, and the night-air should be avoided, 

The diet should be simple but nutritious. In many cases 
alcohol in some form acts beneficially. 

Underlying chronic diseases should always receive appropri- 
ate treatment. When cardiac insufficiency is present, digitalis, 
strychnin, or caffein may be required. When there is anemia 
with general malnutrition, such remedies as iron, arsenic, cod- 
liver oil, and hypophosphites may be given with advantage. 
When gout is a factor, benefit may be expected from the ad- 



586 APPLIED THERAPEUTICS. 

ministration of potassium iodid and alkalis. When renal 
inadequacy is coexistent, the diet must be very carefully 
supervised, and such measures adopted as will promote the 
functional activity of the various emunctories. 

The direct remedies most generally useful are the expector- 
ants of a terebinthinate or balsamic character, such as tere- 
bene, oil of eucalyptus, myrtol, oil of santal, oil of copaiba, 
and oil of cubeb. Tar is another remedy of value. It may 
be used in substance made into pills, or in the form of tar- 
water or the wine of tar. When the sputum is heavy and 
purulent, no drug acts so well as creasote or the carbonate 
of guaiacol. Potassium iodid is of service in some cases, 
but it is difficult to state definitely the exact conditions under 
which it is likely to prove beneficial. It may be tried tenta- 
tively when the expectoration is very scanty and viscid, or 
when there is evidence of a gouty diathesis. In acute ex- 
acerbations recourse must be had to such expectorants as 
potassium citrate, ipecac, antimony, apomorphin, and ammo- 
nium chlorid. 

When the cough is much in excess of what is required to 
expel the exudation, mild anodynes, like codein or heroin, may 
be used from time to time to keep it in subjection. Alkalis 
(sodium bicarbonate, aromatic spirit of ammonia), with or 
without a few minims of the spirit of chloroform, taken in hot 
water before rising, will often lessen morning cough and facili- 
tate expectoration. Dry cough may be largely the result of 
habit, and if this be the case much can be accomplished by 
discipline. 

The following formulae will serve to illustrate the manner in 
which the various remedies may be combined : 

R Terebeni, 

Olei eucalypti, 

Olei santali, aa fgi-fgiss (4.0-6.0 c.c); 

Codeinae, gr. iij-vj (0.2-0.4 gm.). 

Misce et pone in capsulas No. xxiv. 
Sig. — One after each meal and at bedtime. 

R Terpini hydratis, gj (4.0 gm.) ; 

Guaiacolis carbonatis, ^ij (8.0 gr.); 

Strychninae sulphatis, gr. ss (0.03 gm. ) ; 

Codeinae, gr. iij (0.2 gm.). 

Misce et pone in capsulas No. xxiv. 
Sig. — One or two capsules three or four times a day. 

R Apomorphinae hydrochloridi, gr. ss (0.03 gm.); 

Syrupi pruni Virginianae, f^ij (60.0 c.c.) ; 

Syrupi picis liquidae, f^iv (120.0 c.c). M. 

Sig. — A tablespoonful thrice daily. (Murrell.) 



DISEASES OF THE RESPIRATORY SYSTEM. 587 

Inhalations are sometimes efficacious, especially when the 
disease appears to be situated chiefly in the trachea and larger 
bronchi. The volatile agent may be used in a special steam 
nebulizer, or preferably, if the patient must be about, in an 
oro-nasal respirator. The most suitable drugs for inhalation 
are terebene, eucalyptol, oil of Scotch fir, creasote, carbolic 
acid, iodin, compound tincture of benzoin, and spirit of chloro- 
form. A number of these remedies may often be combined 
with advantage, as in the following formula : 

R Chloroformi, fjss-fjj (2.0-4.0 c.c.) ; 

Creosoti, 

Terebeni, 

Olei pini sylvestris, aa fgiss (6.0 c.c.) ; 

Alcoholis, q. s. ad fgj (30.0 c.c). 

Sig. — From 5 to 20 drops to be used in the inhaler several times a 

day. 

Intratracheal injections have given good results in certain in- 
stances. From 1-3 fl. dr. (4.0-1 1.0 c.c.) of a 1 per cent, solu- 
tion of creasote or guaiacol, or of a 2 per cent, solution of 
menthol in olive oil may be injected between the vocal cords 
into the trachea once a day, a syringe with a long curved 
cannula being used for the purpose. The fluid should be in- 
jected in three or four separate portions, while the patient takes 
a slow, full inspiration. 

Inhalation of compressed air by means of Waldenburg's 
apparatus, the pneumatic cabinet, or a pneumatic chamber like 
that in use at Brompton Hospital, affords considerable relief in 
some cases. According to Oertel, the good effects of the com- 
pressed air are to be attributed to the increased pressure within 
the bronchi, causing a diminution of the hyperemia, and, con- 
sequently, less exudation of serum into the bronchial walls and 
less pressure on the lymphatic system. 

Counterirritation, preferably with iodin or small blisters, is 
often of great service in lessening the severity of acute exacer- 
bations. 

ASTHMA, 

The cause must be sought for in every case, and removed if 
possible. When the source of the reflex irritation is in the 
nasal passages, local treatment may be followed by marked 
improvement, or even cure. In a certain number of cases the 
source of the primary irritation is in the stomach, consequently 
digestive disturbances should always receive careful attention. 
Chronic bronchitis, emphysema, and dilatation of the heart are 
frequent concomitants of asthma and call for special treatment. 



588 APPLIED THERAPEUTICS. 

A general toxemia, such as occurs in gout, may be responsible 
for the attacks, and if this be the case appropriate measures 
must be employed to remove or control it. Unfortunately, in 
the majority of cases the chief etiologic factor appears to be a 
peculiar hyperesthesia of the bronchial mucosa, a morbid con- 
dition which at present we have no very potent means of com- 
bating. 

Although we are unable fully to meet the causal indication 
in many instances, nevertheless much can often be done by 
well-directed hygienic measures and empiric medication to 
lessen the frequency and severity of the paroxysms. The diet 
should consist of plain, readily digestible food. A light even- 
ing meal is advisable, especially when the paroxysms tend 
to occur at night. Vicissitudes of temperature must be care- 
fully guarded against and flannel always worn next to the skin. 
Much benefit is often derived from systematic exercise in the 
open air and from hydrotherapy, judiciously employed. 

In delicate, poorly nourished subjects the administration of 
iron, cod-liver oil, hypophosphites, and other tonics does much 
good. A change of climate, even though slight, generally 
proves of decided service, but the choice of locality must be 
determined very largely by the personal experience of the 
patient. Many sufferers do better in the smoky atmosphere of 
cities than in the country. Asthmatics with moist bronchial 
catarrh usually do well in a dry, warm climate, while those 
with dry catarrh generally derive more benefit from an atmos- 
phere that is somewhat humid (see p. 585). Elevated regions 
are mostly unsuitable for old persons with emphysema, but in 
young adults they may prove very advantageous. The inha- 
lation of compressed air has been highly recommended by Ber- 
tin, Sandahl, Theodore Williams, and others. If employed, it 
is best carried out by means of the pneumatic cabinet or the 
" air-bath." The inhalation of oxygen has also been advocated. 

Among special remedies potassium iodid holds the first 
place. While it often fails entirely, it undoubtedly possesses 
more power in averting attacks than any other drug. To be 
effective, it must be given in doses of from 5-20 gr. (0.3-1.3 
gm.) three times a day for long periods. Sodium or strontium 
iodid is sometimes better borne by the stomach than the potas- 
sium salt. Tincture of belladonna, in doses of 3-5 min. 
(0.2-O.3 c.c), thrice daily, is a valuable adjunct to the iodid. 
Arsenic has long been esteemed as a potent remedy, and may 
be tried when iodids prove of no avail. Grindelia robusta (see 
p. 283) is sometimes useful when there is much bronchial 
catarrh. Strychnin is of service in cases associated with em- 



DISEASES OF THE RESPIRATORY SYSTEM. 589 

physema. Occasionally the prolonged administration of bro- 
mids, by allaying the nervous erethism, seems to increase the 
interval between the attacks. Nitroglycerin has also been 
highly extolled by some writers, but its action is uncertain and 
equivocal. VonNoorden has recently recommended the use 
of atropin, giving first a daily dose of y^- gr. (0.0005 g m -) an< ^ 
cautiously increasing this until ^ gr. (0.004 g m -) * s given daily, 
and then gradually diminishing the dose. He repeats such a 
course of treatment every few months, using less of the drug 
each period. 

The Attack. — The most suitable remedy for a particular 
case can only be determined by trial. A drug or a combination 
of drugs that succeeds admirably in one case may fail utterly 
in another. As a rule, drugs which are taken by inhalation 
give the most speedy relief. Some patients derive great benefit 
from the fumes of ignited stramonium or belladonna leaves or 
paper which has been impregnated with potassium nitrate. 
These agents may be burnt in the patient's room or smoked in 
a pipe or in the form of cigarets. Occasionally tobacco proves 
very efficacious. Marked alleviation of the paroxysms is often 
obtained from the inhalation of amyl nitrite (5-6 min. — 0.3- 
0.4 c.c.) or ethyl iodid (10-20 min. — 0.6-1.2 c.c). In some 
cases the paroxysms yield readily to a few whiffs of chloro- 
form, though generally the effects of the drug are only tempo- 
rary. 

When there is decided turgescence of the nasal mucosa, such 
as occurs in the asthma of autumnal catarrh, the topical use of 
adrenalin solution (1 : 5000), applied on a pledget of cotton or 
as a spray, will be found very effective. If such measures fail 
to afford relief, internal remedies must be used. In some cases 
strong hot coffee acts most happily ; in others more benefit is 
derived from hot whisky and water. Among the numerous 
special remedies which have been advocated the following 
appear to be the most reliable : opium, belladonna, bromids, 
chloral, paraldehyd, Hoffmann's anodyne, lobelia, and que- 
bracho. 

Few attacks will resist the action of morphin hypodermically 
with atropin, but the greatest caution must be exercised in 
order that the patient may not become addicted to the drug. 
Heroin hydrochlorid hypodermically in doses of from -^ t° -fa 
gr. (0.005-0.006 gm.) may often be substituted for morphin 
with great advantage. When the attacks are associated with 
bronchial catarrh a combination like the one suggested on page 
283, or the following, will be found of value : 



590 APPLIED THERAPEUTICS. 

R Tincturse belladonna, fgj (4.0 c.c.) ; 

Tincturae lobeliae, fgiij (ii.oc.c); 

Fluidextracti aspidospermatis, f^ss (i5.0c.cl; 

Spiritus setheris compositi, f^v (18.5 c.c.) ; 

Strontii bromidi, 3'ijss (10.0 gm.); 

Elixiris aromatici, q. s. ad f^iv (120.0 c.c). M. 

Sig. — A dessertspoonful in water every two or three hours. 

Among other measures that have been found useful in alle- 
viating asthmatic attacks may be mentioned the application of 
sinapisms to the chest, the inhalation of compressed air, and 
the inhalation of oxygen. 

EMPHYSEMA. 

The treatment of emphysema is chiefly that of the accom- 
panying disease. The various means suggested for the cure or 
relief of chronic bronchitis (see p. 585) may often be used here 
with great advantage. When asthma is the primary disease, 
treatment calculated to lessen the frequency and severity of 
the paroxysms should be instituted (see p. 587). 

When fully established, emphysema is incurable, although it 
is susceptible to alleviation. Violent exercises and over- 
exertion of all kinds must be proscribed. A diet that is light 
but sustaining is indicated. All foods likely to induce flatu- 
lence should be avoided. Much benefit is often derived from 
a change of climate, the choice of locality, however, depending 
somewhat upon the character of the complicating bronchitis 
(see p. 585). As a rule, high elevations are to be avoided. 

The inhalation of compressed air by means of the pneumatic 
cabinet or the " air-bath " is usually followed by a marked im- 
provement in the symptoms. The inspiration of compressed 
air with expiration into rarefied air has been especially advo- 
cated. Striimpell speaks favorably of rhythmic compression 
of the lower portion of the thorax during expiration, as recom- 
mended by Gerhardt This should be done systematically by 
another person two or three times a day during fifty or sixty 
respirations. 

General tonics, like iron and cod-liver oil, are required in 
some cases to improve the general health. Strychnin, being 
both a respiratory and a cardiac stimulant as well as a general 
tonic, is particularly useful. Digitalis will be found a service- 
able remedy when signs of cardiac insufficiency appear. Am- 
monium carbonate, in conjunction with strychnin and digitalis, 
usually has an excellent effect upon acute exacerbations of the 
bronchial catarrh. At such time sinapisms applied to the chest 
may also afford considerable relief. When sleep is disturbed 



DISEASES OF THE RESPIRATORY SYSTEM. 59 1 

by troublesome cough and oppressive dyspnea no drug is so 
generally useful as heroin. When the breathing is very diffi- 
cult, the face suffused and livid, and the pulmonary circulation 
much impeded, recourse should be had to bloodletting, either 
local or general, according to the urgency of the symptoms. 

CATARRHAL PNEUMONIA. 

Hygienic treatment is of the utmost importance. The 
atmosphere of the sick-room should be kept at an even 
temperature of 6S°-yo° F. (20°-2i° C), and should be 
rendered moist with steam. The diet should be liquid and 
nutritious. Milk, light broths, gruels, egg-white, and junket 
are suitable forms of nourishment. Alcoholic stimulants are 
often required. When the circulatory depression is pronounced, 
whisky or brandy may be given in doses of from 10 to 30 min. 
(0.6-2.0 c.c.) in milk to a child of two years every two or three 
hours. 

At the outset it is often advantageous to administer a mild 
purgative, preferably calomel or castor oil. In the absence of 
any special indication for local treatment it will only be neces- 
sary to provide ample protection for the chest. This may be 
done satisfactorily by means of the jacket of cotton-wool. 
When there is harsh, dry cough, mild rubefaction produced by 
the application of the tincture of iodin of suitable strength 
generally affords some relief. In adults sinapisms or stupes 
may be used instead of the iodik. 

Fever is best controlled by outward applications. Com- 
presses wrung out of cold water may be wrapped around the 
chest and changed for fresh ones at intervals of from twenty to 
thirty minutes. This treatment not only serves to lower tem- 
perature, but it also affects very favorably the pulse and respira- 
tion, and conduces to sleep. When the fever is high recourse 
should be had to cold packs or cold baths (85°-8o° F. — 29.5 °- 
26.5 ° C). 

Expectorants are almost invariably required. In the early 
stage, when the cough is harassing and the sputum viscid, 
potassium citrate is very serviceable. It may often be com- 
bined advantageously with spirit of nitrous ether and solution 
of ammonium acetate, as in the following formula : 

R Potassii citratis, ^iss (6.0 gm.) ; 

Spiritus aetheris nitrosi, f^vj (22.5 c.c.) ; 

Liquoris ammonii acetatis, f^j (30.0 c.c); 

Syrupi tolutani, 

Aquse, aa q. s. ad f^iv (120.0 c.c). M. 

Sig. — Dessertspoonful every three hours for a child of three yeare. 



592 APPLIED THERAPEUTICS. 

Later, the ammonium salts, especially the carbonate, are 
more efficacious. From I to 2 gr. (0.06-0.13 gm.) of the latter 
may be given every three or four hours to a child of two years. 
Ammonium iodid is also useful in facilitating expectoration, and 
may be employed as an adjuvant, as in the following formula : 

R Ammonii carbonatis, gr. xlviij (3.1 gm.); 

Ammonii iodidi, gr. xxiv (1.5 gm.) ; 

Syrupi tolutani, 

Syrupi acaciae, aa q. s. ad f^iij (90.0 c.c). M. 

Sig. — Teaspoonful every two or three hours for a child of three 
years. 

In adults the author has found creasote carbonate to be a 
reliable expectorant. When the bronchial secretion is very 
abundant belladonna is a valuable remedy. To a child of two 
years a min. (0.06 c.c.) of the tincture may be given every 
hour or two until the desired effect is produced. When the 
child is unable to expel the accumulated mucus and the breath- 
ing becomes much oppressed, an emetic (ipecac, alum, or zinc 
sulphate) will generally prove of great service. Inhalations of 
oxygen sometimes lessen cyanosis and make the breathing 
easier. Strychnin is also of benefit at this time in combating 
respiratory failure. When these measures fail to afford relief 
alternate douches of hot and cold water should always be tried, 
since by provoking violent respiratory efforts they may serve 
to dislodge the retained secretion and to bring about a thor- 
ough inflation of the lungs. 

If the symptoms of cardiac failure are especially pronounced, 
digitalis must be given in addition to alcohol and strychnin. 
Extreme restlessness and insomnia will sometimes require the 
use of the bromids or some other mild sedative. 

Except at the onset, when their administration may be neces- 
sary to relieve pleuritic pain and to control harassing cough, 
opiates should not be used. 

PULMONARY TUBERCULOSIS. 

Prophylaxis. — Efforts intended to prevent the extension 
of tuberculosis should be made in two directions, that of 
checking the dissemination of the bacillus, and that of ren- 
dering the tissues of the individual less susceptible to infec- 
tion. 

The Bacillus. — As the sputum of consumptive patients is 
the chief source of the bacillus, the disposition of this secre- 
tion becomes of the utmost importance. Such patients should 
be impressed with the danger, both to themselves and others, 



DISEASES OF THE RESPIRATORY SYSTEM. 593 

of indiscriminate spitting, and should be taught never to ex- 
pectorate except in a proper receptacle. To be suitable, the 
spittoon should be provided with a closely fitting cover, and 
should be of such construction that it can be readily cleansed 
and disinfected. It should contain at all times some disin- 
fectant fluid, such as a 5 per cent, solution of carbolic acid, 
and should be thoroughly scalded with boiling water at least 
twice a day. A very good cuspidor, and one that can be 
burned when filled, is made of impervious cardboard. Feeble 
bed-ridden patients should expectorate in moist rags or paper 
napkins, which should be burned before they have become 
dry. It need scarcely be said that the sputum should never 
be swallowed. 

Consumptive patients should always sleep alone. Their 
rooms should be freely accessible to the sunlight, well venti- 
lated, and kept scrupulously clean. Stuffed furniture, carpets, 
and woolen hangings are undesirable. All articles used by 
the patient and liable to be contaminated with sputum should 
be disinfected by means of scalding water. 

Rooms which have been vacated by consumptives should 
not be occupied again until they have been thoroughly disin- 
fected (see p. 387). 

Phthisical patients should refrain from kissing and other 
modes of salutation necessitating very intimate association. 
Tuberculous mothers should not suckle their children. The 
marriage of consumptives should be discouraged. 

Through the enactment and rigid enforcement of special 
laws much can be done by the State to limit the dissemination 
of tuberculosis. Laws should be enacted providing for the 
systematic inspection by skilled veterinarians of all dairies 
and slaughter-houses with the view of declaring unmarket- 
able the milk and meat of tuberculous animals. 

Compulsory registration of phthisical patients, although it 
entails great hardships on individuals and their families, is 
desirable. Flick is probably right in recommending that 
consumptives in the infectious stage of the disease should be 
retired from occupations in which they can infect others. 
Spitting upon sidewalks and the floors of public buildings 
and conveyances should be made a penal offence. Finally, 
the State should provide special hospitals for the indigent 
suffering from tuberculosis. 

The Individual. — Persons with a marked predisposition to 
tuberculosis, whether hereditary or acquired, can do much to 
increase their power of resistance by strict attention to 
hygiene. Fresh air and sunlight, a healthy residence, an 

38 



594 APPLIED THERAPEUTICS. 

outdoor occupation, the wearing of warm clothes, with flan- 
nel next to the skin, a diet of wholesome and nutritious food, 
temperate living, systematic exercise, and daily cold sponging, 
followed by friction of the skin, are the factors to be relied 
upon in attempting to overcome individual susceptibility. 

Persons recovering from catarrhal pneumonia, pleurisy, 
measles, whooping-cough, influenza, and other diseases which 
predispose to tuberculosis should be treated with the utmost 
care. As enlarged tonsils, adenoid growths, and other ob- 
structions in the upper air-passages, by interfering with free 
respiration, increase the risk of infection, they should be re- 
moved. 

Finally, all local foci of tuberculosis, such as frequently 
appear in the cervical lymph-glands, joints, and bones, should 
receive immediate attention. 

Sanatorium Treatment.— The value of pure air in the 
treatment of pulmonary tuberculosis is universally admitted. 
By adding to pure air an abundance of nourishment in a 
readily digestible form, rest alternated with graduated exer- 
cise, and constant medical supervision we supply our phthis- 
ical patient with the best means which medical science has at 
present to offer of securing restoration to health, or, if this be 
impossible, of obtaining alleviation of his symptoms. Indeed, 
if these measures are beyond the reach of the invalid all others 
are likely to prove unavailing. Nowhere are all the means 
just enumerated so available as in a well-managed modern 
sanatorium. Such an institution may be located in almost 
any climate, even within a few miles of a large city, the only 
requisites being moderate elevation, well-drained soil, abun- 
dant sunshine, and protection from cold winds. 

Open Air. — In summer not less than nine or ten hours, and 
in winter not less than six or seven hours, are spent in the 
open air. In Falkenstein the patients remain out of doors in 
their chairs from seven to ten hours a day all the year round, 
in spite of fog, rain, wind, or snow, and even with the ther- 
mometer at 12° C. below zero, and often no sunshine (Knopf). 
Of course, they are sheltered from the wind and rain, and 
are well covered with blankets or fur robes. The bed-room 
windows are kept open both winter and summer. As a rule, 
patients soon accustom themselves to live in a low tem- 
perature without discomfort. 

Nourishment. — When there is no gastric derangement the 
patient is given an ordinary diet of wholesome food, and en- 
couraged to eat as heartily as his digestive capacity will per- 
mit. Milk, eggs, beef, mutton, lamb, fish, fowl, fresh vege- 



DISEASES OF THE RESPIRATORY SYSTEM. 595 

tables, cereals, and fruits are considered suitable forms of 
nourishment. As a rule, the meals are given more frequently 
than in health. Thus, before rising the patient takes hot 
milk, cocoa, or gruel; at breakfast — beef-steak, chops, eggs, 
or fish, bread and butter, and coffee or milk ; at the mid-day 
dinner — soups, fish, meat, vegetables, salad, fruit, and wine; 
at 4 o'clock — milk with bread and butter, milk with raw egg, 
or bouillon with toast; at supper — cold meat, bread and 
butter, cocoa, fresh or preserved fruit ; at bed-time — a glass 
of hot milk or an egg-nog. 

In some cases the anorexia is so pronounced that it be- 
comes necessary to resort to forced feeding, but generally 
the patient can be persuaded to eat, especially if the food be 
presented to him in an appetizing form. Under the influence 
of fresh air the appetite often returns with remarkable rapidity. 

Rest and Exercise. — When the disease is active the patient 
is kept at absolute rest. For most of the day he lies on a 
bamboo couch or a reclining chair in the open air, warmth 
being maintained by abundant covering and, if necessary, by 
a hot stone placed at the feet. In the incipient stage and in 
quiescent tuberculosis moderate exercise is generally recom- 
mended, every precaution being taken, however, to guard 
against fatigue. 

Medical Supervision. — This is an important item of the sana- 
torium treatment. Everything that the patient does is re- 
viewed by the attending physician, and the treatment is re- 
duced to an organized system. " Success depends upon the 
ability of the doctor to discriminate and to shape his treatment 
according to the physical and mental wants of each individual 
case ; the patient must not be made to feel that he is merely 
an inmate of an institution the regime and regulations of which 
he has rigidly to observe, but rather, that he is a well-liked 
guest, who, while conforming to certain rules of the house 
for the benefit of his health, is at liberty otherwise to enjoy 
life in his own fashion " (Muthu). 

The results obtained under the sanatorium treatment fully 
justify its employment; it undoubtedly gives the patient in 
the early stage of the disease the best chance of complete 
recovery. The shortest period of treatment which will benefit 
a patient is rarely less than three months, and to secure a 
lasting improvement he should remain at least six months. 

Climatic Treatment. — Since the open-air treatment has 
been shown to be about equally successful in nearly all coun- 
tries, the selection of a special locality has become a matter 
of secondary importance. Still, there are some patients, with 



596 APPLIED THERAPEUTICS. 

ample means at their disposal, to whom a protracted stay in 
a sanatorium would become exceedingly irksome and dis- 
tasteful. To such patients prolonged residence in a favorable 
climate offers the greatest hope of cure. The requisites of a 
suitable climate are purity of atmosphere, equability of tem- 
perature, and abundance of sunshine. The age of the patient, 
the extent and type of the disease, and the condition of the 
other organs must be carefully considered in deciding the 
question of altitude, of temperature, and of humidity. Other 
matters which should not be overlooked in choosing a locality 
are wholesome food in abundance and well-prepared, good 
accommodations, and available medical advice. 

Young subjects with considerable constitutional vigor, who 
have but a small area of lung involved, generally do well in 
high altitudes, such as are found in Colorado, Wyoming, and 
Montana, and in Switzerland (Davos and St. Moritz). The 
presence of cardiac disease, albuminuria, or emphysema is to 
be regarded as a contraindication to high elevations. 

The moderate elevation of the Adirondack Mountains and 
of the mountains of North Carolina is well adapted to many 
patients who have but a limited area of pneumonic consolida- 
tion, and who cannot afford to remain away from home longer 
than a few months. 

Phthisical patients who have much tendency to bronchial 
catarrh, and who manifest great constitutional irritability, gen- 
erally do better in warm climates with little elevation, such as 
Southern California, Southern Arizona, and Florida in this 
country, and the Riviera and Egypt abroad. 

In some cases an extended sea-voyage is very useful. Ac- 
cording to Douglas Powell, it is most suitable to patients in 
the early stages, who have been previously healthy, who have 
overworked nervous systems, and in whom the disease is 
more or less quiescent. 

Patients in the advanced stages of the disease should not 
be sent far from home. 

Treatment at Home. — The large majority of patients 
are unable to avail themselves of the advantages afforded by 
a stay in a sanatorium or by residence in a salubrious climate. 
These may be consoled by the fact that not a few cases of 
phthisis do well at home when the conditions are not too 
unfavorable. Treatment at home should be made to imitate 
as closely as circumstances will permit that which is followed 
in the sanatorium. An earnest attempt should be made to 
secure the freest possible supply of air and of sunlight. The 
airiest and sunniest room in the house should be selected for 



DISEASES OE THE RESPIRATORY SYSTEM. S97 

the patient. So long as he has fever absolute rest should be 
insisted upon. During the day, if the weather be clement, he 
should rest in a reclining chair in the open air for from six to 
ten hours, according to the season, and at night sleep with 
the windows open. There is no danger, even in the presence 
of fever and sweating, in breathing cold air, providing the 
body itself is kept warm. As much nourishing food should 
be supplied as the digestive capacity of the patient will allow. 

Artificial Aerotherapeutics. — Inhalations of rarefied 
air by means of the pneumatic cabinet have been found very 
beneficial by Piatt, Quimby, Knopf, and others. A reduction 
of the atmospheric pressure about half a pound to the square 
inch is sufficient. According to Knopf, the seances should be 
given at first every day, and their duration should be grad- 
ually increased from two minutes to six or eight minutes. 

C. Theodore Williams, who has had a large experience in 
the treatment of phthisis by means of compressed air, con- 
cludes that beyond lessening slightly the cough and expec- 
toration, the baths are of no benefit. On the contrary, in 
several of the cases hemoptysis came on either in the bath or 
shortly after the treatment. 

Medicinal Treatment. — The chief indications in the me- 
dicinal treatment of tuberculosis are to increase the resisting 
power of the tissue, to reduce the local irritation, and to 
relieve the distressing symptoms. It is the opinion of most 
clinicians of large experience that tuberculin (see p. 435) is of 
definite but limited value. Its administration, however, de- 
mands extreme care, as in unsuitable cases or in too large 
doses it is capable of doing irreparable harm. Patients who 
have little or no fever and whose general nutrition is fairly 
good are the ones most likely to be benefited by it. On the 
other hand, it should be avoided when there is rapid emacia- 
tion, high fever, a persistently frequent pulse, or active nephritis. 
Recent hemoptysis is also to be regarded as a contraindication. 
The dosage may be regulated either by following the opsonic- 
index curve or by closely observing the clinical manifestations. 
At no time should the quantity injected be enough to cause an 
immediate subjective or objective reaction. 

In the last fifty years no remedy has been so universally 
esteemed in the treatment of phthisis as cod-liver oil. When 
well tolerated and digested it is undoubtedly of service in im- 
proving the general nutrition. It is to be regarded, however, 
as a food rather than as a medicine. If it occasion nausea, 
impair the appetite, or derange the digestion in any way, it 
should be withdrawn. The best methods of administering 
cod-liver oil have been considered on p. 304. 



598 APPLIED THERAPEUTICS. 

Olive oil, cream, and butter may be used as substitutes for 
cod-liver oil when the latter is not well borne. 

Arsenic is another remedy which has many warm advocates. 
To be effective it must be given in small doses for several 
months. Jacobi speaks highly of arsenic in conjunction with 
digitalis in tuberculosis of childhood. 

Alcohol is useful in some cases, but not in all. Each case 
must be carefully considered by itself. The danger of induc- 
ing the alcoholic habit must also be borne in mind. Malt 
liquors and wines are usually the best preparations when 
digestion is good, but when the digestive power is feeble 
whisky or brandy, well diluted, is preferable. Alcohol is best 
given with the food. 

Various drugs which have tonic properties and tend to 
improve the general nutrition are of service in phthisis. Of 
these the most valuable are the hypophosphites y strychnin, and 
other vegetable bitters. 

Preparations of iodin seem to be useful, especially in the 
early stages of the disease. A good method of administering 
iodin without deranging digestion is that of Flick, which is 
to rub into the chest twice daily an ointment (10 per cent.) 
of europhen, a compound containing a large percentage of 
loosely combined iodin. 

Creosote (see p. 284). — While the view is no longer ten- 
able that creosote exerts a specific influence on the tubercle 
bacilli, the testimony of numerous observers is convincing 
that the drug is of value in allaying cough and in lessening 
expectoration. It is especially useful when the sputum is 
very abundant and purulent. Creosote carbonate and guaiacol 
carbonate (see p. 286) do not have the disagreeable odor and 
taste of creosote itself, and appear to be equally efficacious. 

Counter irritation. — This is a method of treatment less fre- 
quently employed than its merits justify. Counterirritation 
by iodin or, better, by small " flying " blisters, has seemed to 
the author to be of the greatest use, especially in chronic pul- 
monary tuberculosis. 

Treatment of Special Symptoms. — Digestive Disturb- 
ances. — In a large number of phthisical cases the first indica- 
tion is to correct disordered digestion. No medicines likely 
to irritate the stomach should be ordered. Only the most 
bland and readily digestible forms of nourishment should be 
allowed. The time of eating, as well as the character of the 
food, should be carefully revised. No special rules can be 
laid down for treatment. The various measures and drugs 
which are serviceable in the ordinary forms of indigestion 



DISEASES OF THE RESPIRATORY SYSTEM. 599 

(see p. 555) are applicable here. The most potential measures 
are fresh air and rest. Acute indigestion brought on by over- 
eating is often promptly relieved by a mercurial purge fol- 
lowed by a saline. When anorexia and slow digestion are 
the chief features, an alkali with a vegetable bitter before 
meals (see p. 175) may have a very happy effect. 

Vomiting that is dependent upon extreme irritability of the 
stomach is often relieved by such sedatives as bismuth sub- 
nitrate and hydrocyanic acid (see p. 160), taken before meals. 
Emesis excited by cough sometimes subsides when the patient 
is kept in bed and put on a liquid diet. Chloroform-water 
taken a few minutes after the meals is useful. Counterirrita- 
tion over the diseased area in the lung is very often successful. 
Vomiting occurring shortly after a meal and preceded with a 
sense of suffocation, with or without coughing, is best con- 
trolled by the administration of from 5-10 minims (0.3-0.6 
c.c.) of liquor potassae (Habershon). Vomiting caused by 
ulceration of the epiglottis or larynx will call for local anes- 
thetics — cocain, iodoform, orthoform, and morphin. 

Cough. — In many cases of phthisis cough is indispensable, 
and is best treated by promoting expectoration. For this 
purpose creasote, guaiacol carbonate, terebene, oil of euca- 
lyptus, myrtol, and santal oil are reliable remedies. They 
may often be combined advantageously with strychnin. Ex- 
pectorants in the form of syrups should be avoided. Morning 
paroxysms of cough are often made more easy by the admin- 
istration of a glass of hot water before rising, to which aro- 
matic spirits of ammonia has been added. Intratracheal injec- 
tions (see p. 587) are also useful in modifying bronchial secre- 
tion and promoting expectoration. 

Hard, dry cough calls for special treatment. When such 
cough results from habit, as is sometimes the case, it can be 
suppressed by discipline. Absolute rest is a valuable aid. 
Inhalations of creasote, chloroform, and volatile oils (see p. 
587) are often very effective. Inhalations of formalin have 
been highly recommended by Murrell, Muthu, Huggard, and 
others. The strength of the solution should at first not 
exceed 2 or 3 per cent, of ordinary formalin in alcohol. From 
5-10 minims (0.3-0.6 c.c.) of this solution should be used from 
time to time in an inhaler placed over the mouth only, the 
entire time of the inhalation being from three to six hours 
daily. The strength of the solution may be gradually in- 
creased to 6 per cent., or even to 10 per cent. When the 
cough is very irritable chloroform may be added to the 
inhalation. 

In many cases of chronic phthisis no measure proves so 



600 APPLIED THERAPEUTICS. 

successful in relieving cough as blistering. Periodic fits of 
cough at night call for warm, demulcent, nourishing liquids, 
such as milk or beef-tea, with a little brandy, if there be much 
exhaustion (J. Mitchell Bruce). 

When the cough is very violent and occasions exhaustion 
it may be necessaiy to resort to internal sedatives. Of these, 
those least objectionable are codein, heroin, and spirit of chloro- 
form. The combination mentioned on p. 161 or one like the 
following will be found useful : 

R Codeinae sulphatis, gr. vi-viij (0.4-0.5 gm.) ; 

Spiritus chloroformi, fcj (4.0 c.c.) ; 

Glycerini, f|j (30.0 c.c.) ; 

Succi limonis, f5ss (15.0 c.c.) ; 

Aquas, q. s. ad fjiij (90.0 c.c). — M. 

Sig. — A teaspoonful as occasion demands. 

Hemoptysis. — Absolute rest is essential. An ice-bag may 
be placed over the suspected seat of the hemorrhage, but it 
should be removed at once if it aggravate the coughing. Bits 
of cracked ice may be given to the patient to suck. There is 
no more useful internal remedy than morphin, which serves 
to allay excitement and to check cough. It should be given 
hypodermically in full doses. The application of firm liga- 
tures to the limbs, in order to lessen the volume of blood re- 
turning to the lungs, may prove efficacious. 

When the hemorrhage is protracted a saline purge is some- 
times useful. It probably acts by lowering the blood-press- 
ure. The nitrites may prove beneficial in some cases. Among 
other remedies which seem to be of service may be mentioned 
oil of erigeron, fluidextract of hamamelis, and gelatin. Ergot 
cannot be recommended (see p. 378). Inhalations of vaporized 
solutions of astringent drugs, like alum and ferric sulphate, 
are useless. 

The assurance that pulmonary hemorrhage in phthisis is 
not necessarily a dangerous symptom or even a drawback to 
recovery has a most salutary effect on the patient. The pros- 
tration appearing after a first attack of hemoptysis is often, as 
Flint observed, a moral effect rather than the exhaustion caused 
by the loss of blood. 

Night-sweats. — Sponging the body before bedtime with 
vinegar and water, alcohol and water, or formalin and alcohol 
often checks excessive sweating. Dusting the surface with 
a powder of tannoform (1 part) and zinc oxid (3 parts) is also 
effective. A glass of cold milk with brandy just before retir- 
ing sometimes affords relief. The most reliable internal reme- 
dies are atropin, picrotoxin, agaracin, sulphuric acid, and cam- 
phoric acid (see p. 263). 



DISEASES OF THE RESPIRATORY SYS TEA! 6oi 

Pyrexia. — In many cases the pyrexia yields to absolute rest 
in bed or in a reclining chair, combined with life in the open 
air. Cold sponging is to be recommended when the tempera- 
ture is high. In obstinate cases the administration of 2 or 3 
grains (0.13-0.2 gm.) of phenacetin about two hours before the 
temperature is expected to rise may be tried. The high irreg- 
ular fever resulting from secondary infection by pyogenic 
cocci is sometimes favorably influenced by creasote or one of 
its derivatives. 

Pleurisy. — Mild attacks of pleuritic pain generally yield to 
sinapisms or the application of iodin. Strapping the affected 
side also affords relief. Severe pains should be treated by 
the application of a blister and the subcutaneous adminis- 
tration of morphin. The treatment of tuberculous pleurisy 
with effusion is much the same as that of primary pleurisy 
with effusion. Thoracentesis, however, is inadvisable when 
the effusion is only moderate and the patient is very feeble. 

Diarrhea. — Diarrhea the result of indigestion usually yields 
promptly to restriction of the diet, rest, and the admin- 
istration of a mild mercurial or saline aperient. When 
intestinal tuberculosis is present diarrhea becomes a most 
troublesome complication. Large doses of bismuth sub- 
nitrate, combined with opium in some form, may afford 
temporary relief. Combinations of tannigen or of tannalbin 
with intestinal antiseptics like betanaphtol-bismuth, salol, or 
thymol, sometimes prove useful. Pills of lead acetate and 
opium or of copper sulphate and opium occasionally succeed. 

PLEURISY. 

The first indications in the treatment of acute pleurisy are 
to relieve the pain and to check the progress of the inflamma- 
tion. For the first, the application of a blister or of wet or 
dry cups, together with the hypodermic injection of morphin, 
will be found effective. Strapping the affected side from mid- 
spine to mid-sternum with broad strips of adhesive plaster, as 
originally suggested by Frederick T. Roberts, is also very 
useful. Cold applications are not often tolerated. 

Unfortunately, we have no very potent means of checking 
the inflammatory process in the pleura. The patient should 
be kept in bed and restricted to a liquid diet. A mercurial 
or saline aperient may be prescribed at the onset. Acute 
sthenic cases, accompanied by decided fever, are often favor- 
ably influenced by the administration of salicylates, a method 
of treatment which has been warmly advocated by Aufrecht, 
Fiedler, Dock, and others. From 1-1^ drams (4.0-6.0 gm.) 



602 APPLIED THERAPEUTICS. 

of sodium or ammonium salicylate should be given in the 
twenty-four hours, the dose being gradually reduced as the 
good effects become manifest. In asthenic, protracted cases 
of pleurisy the salicylates are of no avail. 

After the acute symptoms have subsided the indications 
are to accomplish the removal of the fluid, to maintain nutri- 
tion, and to secure complete expansion of the lung. 

Removal of Serous Effusion. — Counterirritation by means of 
iodin or flying blisters appears to be useful in promoting 
absorption. In vigorous subjects the administration of saline 
purgatives according to the method suggested by Matthew 
Hay is sometimes followed by improvement. The object of 
this treatment is to deplete the blood of its serum, and thereby 
favor the abstraction of fluid from the lymph- spaces. The 
quantity of fluid consumed by the patient is restricted to a 
minimum, and every morning or every other morning from 
J—i oz. (15.O-30.0 gm.) of magnesium sulphate is given in con- 
centrated solution an hour before breakfast. This produces 
copious watery discharges. 

Diuretics (digitalis, caffein, potassium acetate) are sometimes 
of service, but their action is much less certain than that of 
the purgatives. Potassium iodid has also been extensively 
employed as an absorbent, but is of doubtful efficacy. Dia- 
phoretics (hot-air baths, pilocarpin) cannot be recommended. 

While the effusion eventually disappears in a large propor- 
tion of cases under medicinal treatment alone, much saving 
of time is often effected by an early resort to paracentesis. 
In the author's opinion this operation should not be delayed 
ordinarily longer than ten days or two weeks when the effu- 
sion is considerable and shows no signs of receding. The 
presence of fever is not a contraindication ; indeed, the tem- 
perature often falls upon the removal of the fluid. 

Irrespective of the period of the disease paracentesis is 
demanded: (1) When there is sufficient fluid to excite severe 
dyspnea, cyanosis, persistent cough, or failing pulse ; (2) When 
the fluid reaches the level of the second rib, and there is 
marked dislocation of the neighboring organs. The sus- 
pected presence of pus is always to be regarded as sufficient 
ground for operative interference. 

Paracentesis. — The patient should be brought to the edge 
of the bed, placed in a semirecumbent position with the thorax 
inclined slightly toward the healthy side, and supported by 
an assistant. The most favorable site of the puncture is usu- 
ally the sixth or seventh intercostal space between the mid- 
axillary line and the angle of the scapula. The operation should 



DISEASES OF THE RESPIRATORY SYSTEM. 603 

be done under strict antiseptic precautions. The needle 
should be inserted with a quick thrust along the upper mar- 
gin of the rib, the depth of the puncture being gauged by the 
forefinger. Local anesthesia is not necessary, but if desired 
it may be secured by means of a spray of ethyl chlorid or the 
application of a block of ice which has been dipped in salt. 
Having introduced the canula, the operator should satisfy 
himself that it is freely movable, should hold it in position 
throughout the operation, and as the evacuation proceeds 
should slowly raise the exposed end so as to keep the inner 
opening below the level of the fluid in the pleural sac. The 
aspiration should be effected slowly, and at intervals it should 
be stopped by compressing the conducting tube. Too rapid 
evacuation may excite engorgement of the lung and edema. 

The amount of fluid which should be removed depends 
somewhat upon the size of the effusion and the ease with 
which it can be evacuated. Even with large effusions it is 
rarely necessary to withdraw more than a quart (1.0 L.). 
The removal of small quantities is in many cases followed by 
the rapid absorption of the remainder. Under no circum- 
stances should extreme efforts be made to obtain the largest 
possible amount of fluid. The operation should be termi- 
nated at once if incessant cough, severe pain, dyspnea, palpi- 
tation, tendency to syncope, or other untoward symptoms 
appear. 

When the requisite amount of fluid has been evacuated, the 
needle should be withdrawn quickly from the chest, and the 
puncture closed with adhesive plaster. 

If the exudate reaccumulate, aspiration maybe repeated after 
the lapse of a week or ten days. Free incision of the thoracic 
wall with thorough drainage has given excellent results in 
cases in which the fluid has reaccumulated after repeated 
tappings. 

Occasionally attempts at aspiration are unsuccessful. The 
cause of failure may be plugging of the canula, great thicken- 
ing of the pleura, or encapsulation of the effusion. Under these 
circumstances it may be necessary to make repeated trials 
before a flow can be established. The aspiration of pleural 
exudates is rarely attended by accidents of any kind. Sudden 
death, the result of cerebral anemia, has been reported. Such 
an accident is not likely to occur if the evacuation be effected 
slowly and arrested immediately on the first appearance of any 
untoward symptom. Another grave and even fatal complica- 
tion of thoracocentesis, but also extremely rare, is a peculiar 
form of pulmonary edema, which is manifested by cough, in- 



604 APPLIED THERAPEUTICS. 

tense dyspnea, and profuse albuminous expectoration. Accord- 
ing to Riesman, who has collected 32 cases from the literature, 
the principal cause of this condition seems to be either too 
rapid or too great a withdrawal of fluid. 

To Maintain Nutrition and Secure Complete Expansion 
of the Lung. — Apart from the restriction of liquids the 
diet during the stage of resorption should be abundant and 
nutritious. Tonics like iron, cod-liver oil, and arsenic are 
very useful. After the exudate has entirely disappeared the 
patient should be urged to take such exercises as will bring 
into play the muscles of respiration. Open-air living and 
change of climate are also to be recommended, especially when 
there is a decided phthisical tendency. 

Empyema. — The treatment of empyema is surgical. The 
indications are to evacuate the pus and to secure thorough 
drainage. Simple puncture cannot be recommended, although 
in children repeated tappings sometimes result in cure. In the 
large majority of cases treatment by free incision and the in- 
troduction of a large-sized drainage-tube proves successful. 
Irrigation of the pleural sac should not be practised unless the 
exudate is putrid. 

Excision of one or more ribs (Estlander's operation) or ex- 
cision of the ribs and intercostal tissues (Schede's operation) 
may be necessary when the empyema is of long standing or 
occurs in elderly persons with rigid thoracic walls. Fowler 
recommends, in chronic empyema, decortication of the lung in 
preference to either Estlander's or Schede's operation, claiming 
that it combines the advantages of restoration of the function 
of the lung, so far as this is possible, with closure of the em- 
pyemic cavity. 



DISEASES OF THE CIRCULATORY SYSTEM, 

PERICARDITIS. 

One of the chief indications in the treatment of acute peri- 
carditis is to allay the excited action of the heart. Absolute 
rest of body and mind is imperative. During the first week, at 
least, milk is the most suitable diet. Among local applications 
none is so generally useful in subduing palpitation as the ice- 
bag. Local blood-letting is of great service when the disease 
occurs in a fairly robust subject and is attended with much pain. 
Blistering also serves to allay pain, but it does not seem to exert 
any influence on the progress of the disease. Internally, mor- 
phin is often required to control restlessness and to relieve pain. 



DISEASES OF THE CIRCULATORY SYSTEM. 605 

Drugs which stimulate the cardiac inhibitory mechanism are of 
doubtful utility, although digitalis may be given when accele- 
ration of the pulse is accompanied by decided lowering of the 
arterial tension. If heart failure occur such stimulants as alco- 
hol, strychnin, caffein, and camphor must be employed. 

Pericardial Bffiision.— When the exudate is serofibrin- 
ous, is moderate in amount, and causes no marked subjective 
symptoms, an expectant plan of treatment may be pursued with 
the assurance that resolution will follow in due time. When, 
however, the effusion is extensive and causes some embar- 
rassment of the heart's action, efforts should be made which 
will tend to hasten absorption. Of the value of vesicants in 
this stage there can be no reasonable doubt. If the patient's 
strength will permit, saline purges may be administered in the 
manner suggested by Matthew Hay (see p. 602). Diuretics, 
such as digitalis and caffein, may be tried. Potassium iodid is 
recommended, but it is of doubtful efficacy. Diaphoretics, 
particularly pilocarpin, should not be used. 

In cases in which the symptoms become urgent, or in which 
absorption does not occur after a thorough trial of the remedies 
just mentioned, operative interference becomes necessaiy. In 
the case of serofibrinous effusions, aspiration is the operation 
of choice, although it yields far less favorable results than it 
does in pleurisy. The most suitable site for paracentesis is 
ordinarily in the left fifth intercostal space, about an inch or an 
inch and a half from the edge of the sternum. According to 
Osier, in large effusions the pericardium can also be readily 
reached without danger by thrusting the needle upward and 
backward close to the costal margin in the left costoxiphoid 
angle. In a number of instances, owing to an error in diag- 
nosis, the needle has pierced the right ventricle. Fortunately, 
this accident has rarely produced serious consequences, although 
Broadbent recalls two cases in which it resulted fatally through 
hemorrhage. 

In pericarditis with purulent effusion the indications are to 
incise the sac and to afford the freest possible outlet for the 
pus. Three methods of approaching the pericardium have 
been practised : By incision through an intercostal space, by 
trephining the sternum, and by epigastric incision. C. B. 
Porter excises the cartilage of the fifth rib, ligates the internal 
mammary vessels, and, after introducing a needle to corroborate 
the diagnosis, opens the pericardium obliquely downward and 
outward close to the border of the sternum. He then stitches 
the edges of the pericardium to the skin, irrigates, and intro- 
duces two rubber drainage-tubes. The advantages claimed for 



606 APPLIED THERAPEUTICS. 

this operation are that it avoids opening the pleura and secures 
permanent free drainage. 

The mortality of incision for pyopericardium in 47 cases was 
about 60 per cent. 

ACUTE ENDOCARDITIS. 

The treatment of acute endocarditis is mainly that of the 
causal condition. Too much emphasis cannot be given to the 
need of frequent examination of the patient's heart during the 
course of all acute infections, in particular of acute articular 
rheumatism, even of the mildest type (see page 536). The 
special indication is to secure complete resolution of the in- 
flammatory process or, if this be impossible, to favor the estab- 
lishment of the highest attainable degree of compensation. 
Prolonged ajid complete rest is the most important factor of the 
treatment. The patient should be confined to bed not only 
during the attack, but for several weeks after it has subsided, in 
order to allow sufficient time for the damage to be repaired or 
for compensatory hypertrophy to be thoroughly established. 
In the period of convalescence extraordinary efforts are often 
required to prevent those indiscretions which are so liable to 
cause a fresh invasion of the valves or to strain the already 
overburdened heart. Mental and emotional excitement must 
also be avoided as much as possible, since they both tend to in- 
crease the force and frequency of the pulse. The diet should 
be liquid and unstimulating. For a week or two milk is the 
most appropriate food ; later milk-toast, eggs, thin gruels, light 
broths, and steamed rice are admissible. 

Externally, an ice-bag is often useful in allaying excitement 
of the heart. Internally, at the outset and from time to time 
throughout the illness, mild mercurial or saline aperients may 
be used for their depurative effect. Digitalis may be of service 
when the pulse is weak and irregular, but in the large majority 
of cases this remedy is not indicated. Heart-failure is to be 
combated by such stimulants as alcohol, ammonia, strych- 
nin, and caffein. Morphin is sometimes required to re- 
lieve severe pain, allay nervous perturbation, and to promote 
sleep. To these measures is to be added, of course, the treat- 
ment appropriate to the disease upon which the endocarditis 
has supervened. 

Treatment by continuous vesication and the prolonged ad- 
ministration of potassium iodid has seemed to most practitioners 
of large experience to be of doubtful utility, although it has 
been ardently advocated by Pepper in this country, Andre 



DISEASES OF THE CIRCULATORY SYSTEM. 6oj 

Petit in France, Rosenstein in Germany, and Walsh and Caton 
in England. 

Caton, 1 especially, has presented some very strong evidence 
in favor of these measures as auxiliaries to prolonged rest in 
bed. He reports that of 39 cases of acute endocarditis treated 
by this method, 29 left the hospital with normal heart-sounds 
and 10 with a bruit, and that of 13 treated expectantly 12 left 
the hospital with a bruit. Many of the cases were kept under 
observation subsequently for a long period, and every care was 
taken to make the observations accurate. 



CHRONIC ENDOCARDITIS, 

Period of Compensation. — Treatment during this stage 
must be chiefly hygienic. No specific medication should be 
advised unless there be a definite indication for its employ- 
ment. Our aim should be to maintain the heart-muscle in the 
highest possible state of efficiency by carefully regulating the 
habits of life, preventing excessive cardiac strains, and protect- 
ing the patient against intercurrent diseases likely to induce a 
fresh attack of endocarditis or to weaken the myocardium. In 
many cases it is well to inform the patient of his valvular de- 
fect, without unnecessarily alarming him, in order to secure his 
thorough cooperation. 

Violent exertion, mental fatigue, intense emotional excite- 
ment, intemperance in eating and drinking, and venereal ex- 
cesses are to be rigidly avoided. As a protection against 
rheumatism and bronchitis the patient should habitually wear 
flannel next to the skin, and should avoid unnecessary exposure 
to cold and wet. In the absence of any digestive disturbances, 
a varied diet of plain wholesome food is suitable. The meals 
should be taken at regular intervals, and followed by a rest of 
from twenty to thirty minutes. In elderly persons and those 
inclined to obesity a spare diet is generally advisable. Tea, 
coffee, alcohol, and tobacco should be used very moderately, if 
at all. The bowels should be made to move daily, a mild aperi- 
ent being given if necessary, and the skin should be kept 
active by frequent tepid baths. 

Exercise judiciously employed is often of the greatest bene- 
fit in prolonging the period of compensation. It is very im- 
portant, however, that the muscular efforts should be carefully 
graduated and adapted to the working capacity of the heart. 
The character and duration of the exercises must be deter- 
mined experimentally in each individual case, the subjective 

1 Liverpool Med.-Chirurg. Jour. y July, 1895. 



608 APPLIED THERAPEUTICS. 

symptoms of the patient being taken as a guide. All physical 
effort should stop short of producing palpitation, pronounced 
dyspnea, or fatigue. In persons who have just recovered from 
acute endocarditis the exercise should be confined to massage 
and passive movements, as originally practised in Sweden by 
ling. In cases in which compensation has been completely 
established, but is maintained with some difficulty, exercises 
consisting of movements made against slight resistance, as car- 
ried out by Schott, of Nauheim, may be recommended (see p. 
488). Vigorous patients may derive some benefit from the 
method of treatment urged by Oertel, which consists in grad- 
uated climbing exercises taken in the open air at a moderate 
elevation. 

It is not often necessary to recommend a change of occupa- 
tion unless the patient be engaged in a pursuit requiring a 
great expenditure of energy. Children with chronic valvular 
disease in whom compensation has been perfectly established 
need not be debarred from outdoor games which involve only 
moderate exertion. Thus, baseball, cricket, golf, and lawn ten- 
nis are usually permissible. On the other hand, amusements 
which require sudden or prolonged effort, such as racing, 
swimming, football, and wrestling, had better be avoided. 

General tonics, like iron, arsenic, and cod-liver oil, may be 
used with advantage when there is distinct anemia or impaired 
nutrition. 

Period of Broken Compensation. — The most important 
element in the treatment of this stage of chronic valvular dis- 
ease is absolute rest. Under the influence of this alone it fre- 
quently happens that the urinary secretion increases, the venous 
engorgement and edema subside, and compensation is grad- 
ually restored. While the recumbent posture is generally 
preferable, it is sometimes advisable to consult the inclinations 
of the patient and to allow him to sit up in an arm-chair, prop- 
ped up by pillows and carefully protected from the cold. 

When the digestive functions are well maintained a carefully 
selected mixed diet may be allowed. Eggs, oysters, sweet- 
bread, scraped beef, lean lamb or mutton chops, white meat of 
chicken, boiled fish, baked potato, steamed rice, well-made 
gruels, toast, junket, wine jelly, and plain custard are suitable 
forms of nourishment. Coffee and tea should be used very 
sparingly, if at all. Alcohol in the form of brandy or whisky 
is often of great value. Full evening meals should be avoided, 
the chief meal being taken in the middle of the day. When 
there is much flatulence benefit will be derived from a consid- 
erable limitation of the carbohydrates. When the cavities of 



DISEASES OF THE CIRCULATORY SYSTEM. 609 

the heart are overfilled and there is decided edema, it is often 
very advantageous to reduce the ingestion of liquids to a min- 
imum, although in this as in other matters pertaining to the 
diet we should be guided largely by observation. In severe 
cases it is often a good plan to restrict the diet, at least for a 
time, to milk, giving from 3-4 ounces (90.0-120.O c.c.) every 
two hours. 

Should these measures prove inadequate to restore the equi- 
librium of the circulation, recourse must be had to special 
cardiac stimulants. The best and most reliable of these is 
digitalis. The chief indications for using this drug are fre- 
quency, weakness, and irregularity of the pulse, edema of the 
limbs, and deficient urination. When these symptoms are 
present digitalis may be employed whatever the nature or seat 
of the lesion. From 10-20 minims (0.6-1.2 c.c.) of a good 
tincture may be given two or three times a day (see p. 50). 
The first evidences of its beneficial effects are an increase in the 
secretion of urine and an improvement in the rhythm and tone 
of the pulse. Failure to secure immediate results should not 
cause disappointment, as decided benefit may not be observed 
until thirty-six or forty-eight hours after the institution of 
treatment. Digitalis is of most service in mitral regurgitation. 
In mitral stenosis its action is less certain, but nevertheless /it 
may be prescribed with considerable confidence when there is 
failure of the right ventricle with dropsy and ischuria. In 
disease of the aortic area it must be used with some circum- 
spection. When the chief symptoms are slight dyspnea, pre- 
cordial distress, vertigo, and tendency to syncope, it generally 
fails or acts unfavorably, but when venous congestion, cyanosis, 
and edema appear as the result of back pressure in the heart 
and lungs, it frequently does good. In many cases certain 
adjuvants must be employed before digitalis can be made effec- 
tive. When the right side of the heart is embarrassed and 
the tissues are engorged, purgatives are essential. Without 
their aid digitalis may afford little or no relief. Mercurial 
aperients are specially serviceable in lowering the venous 
tension. An appropriate dose of calomel or blue mass may 
be given in the evening, and followed in the morning by a 
saline. Subsequently, in some cases it is advantageous to 
combine the mercury with the digitalis, as in the well-known 
Niemeyer's pill (see p. 52). When the right ventricle is 
greatly overdistended and cyanosis is marked, venesection to 
the extent of a pint (0.5 L.) or more often affords prompt 
relief. Indeed, in this condition digitalis usually proves wholly 
unavailing when used before the veins have been thus depleted. 
39 



6lO APPLIED THERAPEUTICS. 

Strychnin is one of the most valuable accessories to digitalis 
we possess. It is particularly useful in temporary breakdowns 
of compensation in which there are pulmonary complications. 
When the myocardium is much involved it may often be given 
for many months or even years with benefit. Caffein is 
another remedy that may in many cases be combined advan- 
tageously with digitalis. It is especially serviceable when 
dropsy is a prominent symptom. Its chief drawback is its 
tendency to induce restlessness and insomnia. Excellent re- 
sults are frequently obtained by giving nitroglycerin or one of 
the other nitrites in conjunction with digitalis when there is 
high arterial tension or considerable precordial pain. In myo- 
cardial degeneration it serves a useful purpose as corrigent of 
digitalis in counteracting the constricting effect of the latter on 
the blood-vessels. In cardiorenal disease with persistent or 
paroxysmal dyspnea it is also useful. Iron and arsenic are 
valuable adjuncts to digitalis when there is anemia. The latter 
especially has been highly extolled by Balfour, Bramwell, and 
others in cases of aortic regurgitation and of fatty or fibroid 
heart with anginoid symptoms. 

As a circulatory stimulant strophanthus is distinctly less 
reliable than digitalis, although it is somewhat more prompt in 
its action than the latter. It may be used in the cases in which 
digitalis is not well borne by the stomach or fails to give the 
desired result. It is also very valuable as an alternate when 
the administration of digitalis must be interrupted. Convallaria 
and adonidin may be mentioned as drugs which occasionally 
succeed after digitalis and strophanthus have failed. 

Treatment of Special Symptoms.— Dropsy. — In many 
cases absolute rest in bed, restriction of liquid ingesta, and the 
administration of digitalis suffice to restore compensation and, 
consequently, to remove the dropsy. Gentle massage of the 
affected parts by promoting the lymphatic and venous return 
is often beneficial. The application of smooth firm bandages 
to the swollen limbs sometimes affords much relief. Purgatives 
are very valuable, although some caution must be exercised in 
their employment lest they prove exhausting to the patient 
Salines in concentrated solution, compound jalap powder (30- 
40 gr. — 2.0-2.6 gm.), and elaterin (^ gr.— -0.003 gm.) should 
be tried in the order named. Diuretics are also useful. Digi- 
talis, on account of its favorable influence on the circulation, 
is generally the most suitable. The best adjuvants are caffein, 
the vegetable salts of potassium, theobromin, theocin, and squill. 
The following mixture of potassium acetate and the infusion of 
digitalis often acts happily : 



DISEASES OF THE CIRCULATORY SYSTEM. 6l I 

R Potassii acetatis, ^ij (8.0 gm.) ; 

Infusi digitalis, f^iij (90.0 ex.). — M. 

Sig. — A tablespoonful three or four times a day. 

Another time-honored remedy is the pill containing 1 gr. 
(0.065 gm.) each of blue mass, digitalis, and squill, which may- 
be given every three or four hours until diuresis, free purga- 
tion, or both, are obtained. It is generally inadvisable to em- 
ploy diaphoretics like hot-air or vapor baths and pilocarpin, 
since they may induce profound exhaustion. 

When all other measures have failed recourse may be had 
to paracentesis of the internal cavities and to scarification of 
the most swollen and most dependent parts. The insertion of 
fine silver canulae with thin rubber tubes attached (Southey's 
tubes) often serves to drain off large amounts of fluid. Not 
infrequently curved incisions behind the ankles prove less 
annoying to the patient than either scarification or the insertion 
of tubes. Strict antiseptic precautions must always be taken 
in carrying out any of these operative measures, otherwise 
septic inflammation is very liable to ensue. 

Dyspnea. — Chief reliance must be placed upon those meas- 
ures which have already been recommended as useful in 
restoring the balance of the circulation. Free wet cupping or 
venesection is of the greatest service in relieving dyspnea the 
result of pulmonary engorgement. Counterirritation by means 
of sinapisms is much less efficacious. Oxygen inhalations 
are sometimes useful. Aspiration will be required in cases of 
hydrothorax. The nitrites are very valuable in paroxysmal 
dyspnea or cardiac asthma, especially when high arterial ten- 
sion coexists. Dyspnea excited by flatulent distention of the 
stomach is usually promptly relieved by carminatives — spirit 
of chloroform, Hoffmann's anodyne, or spirit of mint. In 
many cases no remedy is so reliable as morphin. In the later 
stages of heart-disease it is indispensable. It should be given 
hypodermically in doses of from \- \ gr. (0.008 gm.-o.oi gm.) 
combined with atropin (-5-^ gr. — 0.0003 gm.). Morphin 
should not be used, however, when there is edema of the 
lungs. 

Palpitation. — Cold to the precordia is a valuable sedative. 
When there is marked hypertrophy of the heart with a bound- 
ing pulse aconite (1-3 min. — 0.06-0.25 ex., every three hours) 
will be found of service. Palpitation of purely nervous origin 
is often benefited by the administration of bromids. When 
flatulence is an exciting factor carminatives usually afford relief. 
When the attacks are obstinate and interfere with sleep mor- 
phin is to be recommended. 



6l2 APPLIED THERAPEUTICS. 

Pain. — Temporary precordial oppression is often relieved by 
warm or cold applications and the administration of Hoff- 
mann's anodyne or brandy with aromatic spirits of ammonia. 
Severe continuous pain may yield to leeching or blistering. 
In paroxysmal pain of an anginoid character, nitroglycerin 
will generally be found a speedy remedy. In the anginoid 
pains, which frequently occur in aortic disease, potassium 
iodid, 10 gr. (0.65 gm.), thrice daily, is also of service. In 
some cases morphin is the only remedy that will afford com- 
plete relief. 

Cough and Hemoptysis. — These symptoms rarely call for 
special treatment. Cough occurring after failure of compen- 
sation is referable to pulmonary congestion and bronchial 
catarrh, and can be controlled successfully only by remedies 
employed directly against the cardiac failure. Hemoptysis is 
not often excessive and is generally salutary. When it is 
attended with dyspnea and precordial distress it calls for vene- 
section or leeching and aperients. 

Vomiting. — Vomiting may be due to faulty diet or to digi- 
talis or other medicines. In many cases, however, it is of 
serious import, being the result of stasis in the vessels of the 
stomach. In severe cases it is advisable to rest the stomach. 
No food should be given by the mouth except a little iced 
champagne with Apollinaris, brandy with soda-water, or milk 
with lime-water, whey, or liquid peptonoids. Calomel in frac- 
tional doses is useful in depleting the engorged portal system. 
Anti-emetics (see p. 168) are seldom efficacious. Sinapisms 
over the epigastric region sometimes afford relief. Cardiac 
stimulation is best maintained by administering digitalin and 
strychnin hypodermically. 

Insomnia. — In mild cases Hoffmann's anodyne (f3ss-f3j — 
2.0-4.0 c.c.) or a mixture of aromatic spirits of ammonia with 
whisky may suffice. Bromids are sometimes serviceable. Of 
the more active soporifics, veronal, chloralamid, and trional 
are worthy of confidence. Bramwell has found paraldehyd 
very useful in cases in which there is associated bronchitis. 
Chloral should usually be avoided on account of the depression 
it causes. On the whole, no somnifacient is so generally effi- 
cacious as morphin, especially when sleeplessness is attended 
with pain, precordial anxiety, and restlessness. One-sixth of 
a grain (0.0 1 gm.) with y^ gr. (0.0004 gm.) of atropin, hypo- 
dermically, is often sufficient. 

Sudden heart-failure must be met by the administration of 
diffusible stimulants, such as ammonia, alcohol, and ether. 
The application of heat to the precordia is also useful. 



DISEASES OF THE CIRCULATORY SYSTEM. 613 



CHRONIC MYOCARDIAL DISEASE. 

Attention to the minutiae of life is of the utmost importance. 
No one " rule of thumb " can be laid down for every patient. 
Each individual must be carefully studied as regards the state 
of the arteries, the character of the pulse, the digestive powers, 
the existence or absence of any constitutional vice, and the 
actual condition of the heart, so far as this can be ascertained. 
Exercise and diet are the points to which attention should first 
be directed. It is not always necessary that the patient should 
give up his occupation, but it is imperative that the sum of his 
exertions should be carefully adapted to the strength of his 
heart. It must be borne in mind that the fret and worry 
incident to many pursuits may exert as baneful an effect upon 
the circulation as undue physical effort. In some cases when 
the pathologic changes are not far advanced, and particularly if 
they consist in fatty overgrowth rather than degeneration of 
the muscular fiber, graduated exercises coupled with warm 
saline baths, as in the well-known Nauheim treatment (see p. 
488), have a very salutary influence. When, however, palpita- 
tion, irregularity, pain, or pronounced dyspnea follow exertion, 
absolute rest is essential. In such cases massage is very use- 
ful, since it gives the patient the advantages of exercise without 
throwing any strain upon his heart. 

As with exercise so with diet, no hard and fast rules can be 
laid down. The diet must be carefully adapted to the digestive 
powers and to the needs of the system. Rich foods, bulky 
foods, and foods which induce flatulence should be withheld. 
Eating between meals should be prohibited. The question of 
the quantity of food is also a matter of great importance. 
Degenerative changes in the heart usually occur at a period of 
life when the amount of food can often be considerably re- 
stricted without impairing the general nutrition. Chambers, 
Balfour, and others have dwelt upon the advisability of restrict- 
ing the amount of liquids taken with meals in the case of fail- 
ure of the myocardium. By this means the tension in the 
venous system may be lowered and the arterial resistance 
reduced. If thirst be complained of it is better for the patient 
to sip a moderate amount of hot water between meals than 
drink copiously during meals. Some judgment, however, 
must be exercised in the matter of drink, as the amount of 
liquid required to secure a free evacuation of waste products 
from the system must vary in different cases. 

Tea and coffee should be used very sparingly, if at all. 
Alcohol also is better dispensed with. Smoking should be 



614 APPLIED THERAPEUTICS. 

forbidden. Excesses of all kinds must be rigidly avoided. 
Constipation must be relieved. When it does not yield to 
judicious exercise and the regulation of diet, an aloetic aper- 
ient (see p. 565) should be given at night or a mild saline in 
the morning. This may be supplemented from time to time 
by a pill of blue mass. In many cases no single remedy 
affords such prompt relief from the general distress as a mer- 
curial laxative. 

If there be a gouty diathesis it should be met by appropriate 
treatment, and if syphilis be a factor antiluetic remedies should 
be employed. 

As to special treatment, strychnin appears to be the most 
generally useful drug. In doses of from ^ to^- gr. (0.001- 
0.002 gm.), two or three times a day, it rarely fails to be of 
some benefit. When there is anemia iron is a useful adjuvant. 
Arsenic in small doses, over long periods, is often of the 
greatest service. Balfour considers that " arsenic is indispen- 
sable in all forms of weak heart accompanied by pain." He 
recommends it in combination with iron and strychnin, twice a 
day, after food. Nitrites usually prove very beneficial in cases 
in which high arterial tension, anginoid pains, or cardiac 
asthma are prominent symptoms. Huchard and others have 
spoken in the highest terms of the prolonged use of the 
iodids, especially when angina pectoris is a feature of the 
cardiac failure. They are most effective, as Osier has stated, 
in robust middle-aged men in whom the angina is the sole 
symptom. They are contraindicated when the myocardial 
disease is associated with advanced arterial degeneration and 
chronic nephritis. 

Digitalis is of service in some cases. The less advanced 
the degeneration the more likely is it to be useful. Large 
doses are generally badly borne, but persistently employed in 
doses of 2 or 3 minims (0.1-0.2 c.c.) of the tincture, twice a day, 
it often exerts a most favorable tonic effect. Even with these 
small doses of digitalis it may be necessary to guard against 
the constricting influence of the drug on the arterioles by com- 
bining with it a vasodilator, such as nitroglycerin, erythrol 
tetranitrate, or sodium nitrite. Not infrequently tincture of 
strophanthus, in doses of 3 or 4 minims (0.2-0.25 c.c), twice 
daily, proves more efficacious than digitalis. When neither 
digitalis nor strophanthus is well received, cafTein, convallaria, 
or adonidin may be tried. 

For the treatment of the more serious symptoms of cardiac 
failure the reader is referred to the article on Chronic Endo- 
carditis (see p. 607). 



DISEASES OF THE CIRCULATORY SYSTEM. 615 

ANGINA PECTORIS. 

The general treatment of true angina pectoris is for the most 
part that of myocardial degeneration. The patient should lead 
a quiet, easy life, should avoid, as far as possible, all mental and 
physical excitement, and should abstain, as a rule, from tobacco 
and alcohol. Small meals of readily digested food are to be 
recommended. The evening meal especially should be light. 
Muscular exertion or mental excitement after meals is particu- 
larly injurious. The bowels should be kept regularly open, 
mild aperients being used for the purpose if necessary. Un- 
less the heart is very weak and sensitive gentle exercise in the 
fresh air is to be recommended. Cold, however, is to be 
avoided. After a very severe attack it is generally necessary 
to enjoin absolute rest in bed for several days. Any constitu- 
tional disease that may be present, such as gout or syphilis, 
must receive appropriate treatment. In the anemic and debil- 
itated, tonics, especially iron and strychnin, are very useful. 
The most valuable special remedies in the order of their effi- 
cacy are the nitrites, the iodids (see p. 614), and arsenic. 

The Attack. — When the attacks are brought on by indi- 
gestion they can frequently be staved off by the timely use of 
a brisk mercurial or saline purge. Marked flatulency should 
be met by the prompt administration of a stimulant carmina- 
tive like spirit of mint, Hoffmann's anodyne, or spirit of cam- 
phor. For the instant relief of the pain no drug is so useful 
as amyl nitrite. In the majority of cases a mere whiff of this 
speedily arrests the paroxysm. The patient should carry the 
remedy on his person in a small vial or, better, in the form of 
glass pearls containing from 3-5 min. (0.2-0.3 c.c), which 
can be broken in a handkerchief and inhaled as soon as he 
perceives the pain. When the attacks are severe and pro- 
longed, morphin (J-J gr. — 0.016-0.032 gm.) should be given 
hypodermically. In some cases, as Yeo has pointed out, there 
is a remarkable tolerance of this drug. Atropin is a valuable 
adjunct to morphin. When amyl nitrite and morphin fail, 
recourse should be had to chloroform inhalations (see p. 127). 
The application of a mustard plaster to the precordial region 
is often useful. In those cases in which the attacks occur in 
very rapid succession flying blisters or light touches of the 
actual cautery sometimes bring relief. The cardiac depression 
following grave seizures should be combated by such drugs as 
strychnin, ammonia, ether, and camphor. 



6l6 APPLIED THERAPEUTICS. 

DISEASES OF THE KIDNEYS. 

ACUTE NEPHRITIS. 

Absolute rest in bed for a period varying from four to six 
weeks is imperative.* Even after the patient feels perfectly well 
he should not be permitted to leave his bed until the urine has 
been absolutely free from albumin for at least a week. 

The patient should be well covered, woolen being worn next 
to the skin, and great care should be taken to guard against 
draughts. 

The best diet for acute Bright's disease is milk. While it is 
desirable to add to the milk one-fourth or one-third part of 
lime-water, barley-water, carbonated water or Vichy, it is not 
advisable for the patient to drink excessive quantities of water. 
Beef-tea and broths should be interdicted. When the kidneys 
begin to secrete more actively, thin gruels, rice, and milk-toast 
may be given. During convalescence, bread and butter, baked 
potatoes, green vegetables, and fruits are permissible. The 
return to nitrogenous food should be most gradual, the effect 
on the urine of each addition to the diet being carefully 
watched. 

In the absence of any direct remedies the indications are to 
divert the blood from the inflamed kidneys, to lessen their 
work as much as possible by increasing the action of the bowels 
and skin, and to meet the symptoms as they arise. 

At the onset, if there be pain or suppression of urine, dry 
cupping, or, in severe cases, wet cupping, over the region of 
the kidneys is of value. Following the cupping warm poul- 
tices may be applied to the loins with advantage. Cantharides, 
turpentine, or similar drugs are not to be used. 

The bowels should be kept freely opened by means of daily 
purges, the best in this condition being salines in concentrated 
solution and compound jalap powder. For children magnesia 
will be found sufficient. Very vigorous purgation is not called 
for unless there be dropsy or uremia. 

Free sweating is very useful in promoting elimination by 
the skin. It may be effected by means of hot-water baths, 
hot packs, vapor baths, or hot-air baths (see p. 494). In chil- 
dren hot baths and hot packs are eminently satisfactory, espe- 
cially if spirit of nitrous ether or solution of ammonium acetate 
be administered at the same time. If the baths afford but 
little relief their action may be supplemented by the hypoder- 
mic administration of pilocarpin in doses of from ^ 6 - ■ ^ gr. 
(0.004-0.0065 gm.). 



DISEASES OF THE KIDNEYS. 617 

There is much difference of opinion as to the use of diuret- 
ics. Some observers believe that all diuretics are irritating to 
the kidneys and therefore should be withheld at least during 
the stage of engorgement. Most authorities admit, however, 
that mild alkaline diuretics, like the vegetable salts of potas- 
sium, often serve a useful purpose in removing from the urinif- 
erous tubules proliferated epithelium, albuminous plugs, and 
effete matter. From 20-30 gr. (1.3-2.0 gm.) of the citrate 
or acetate of potassium may be given three or four times a day, 
well diluted. Later in the disease, when the pulse tension 
falls, experience has proved that digitalis is often of great 
value. From 2-4 fl. dr. (8.0-15.0 c.c.) of the infusion should 
be given every three or four hours. It may be combined 
advantageously with an alkaline diuretic as in the following 
formula : 

R Potassii acetatis, ^ij (8.0 gm.); 

Infusi digitalis, fjjiij (90.0 c.c). M. 

Sig. — A tablespoonful, well diluted, every four hours. 

Symptomatic Treatment. — The symptoms of acute 
nephritis which may demand special attention are excessive 
dropsy, uremia, nausea and vomiting, and anemia. 

Excessive Dropsy. — When the dropsy is extreme and does 
not yield to the purgative, diaphoretic, and diuretic remedies 
which have already been indicated, recourse must be had to 
puncture of the swollen parts, to free incision on the inner or 
outer side of each ankle, or to the insertion beneath the skin 
of South ey's tubes (see p. 611). 

Large accumulations in the serous sacs should be removed 
by paracentesis. 

Uremia. — This complication calls for very prompt and ener- 
getic treatment. The chief indication is to favor the elimina- 
tion of effete matter through the only available emunctories — 
the bowels and the skin. Two drops (0.065 c.c.) of croton oil, 
diluted with olive oil or glycerin, or \ gr. (0.0 1 gm.) of elate- 
rium should be given at once. Sweating should be promoted 
by hot-air or vapor baths and the hypodermic administration 
of pilocarpin (-j— J- gr. — 0.015-0.02 gm.). If coma or convul- 
sions appear, and the patient is not too feeble, venesection may 
be practised, the removal of from 15 to 20 ounces (450.0- 
600.0 c.c.) of blood sometimes exerting a very happy effect. 
In children a few ounces of blood may be abstracted from the 
loins by means of wet cups. Hypodermoclysis is another 
potent remedy (see p. 496). It may be resorted to whether 
blood-letting is deemed necessary or not, although it is more 



6l8 APPLIED THERAPEUTICS. 

efficacious when practised after blood has been withdrawn. 
Enteroclysis (see p. 498) is also useful, though less effective 
than the subcutaneous injection of salt solution. 

Convulsions may be controlled by chloroform inhalation or 
the administration of chloral. If the patient be unable to 
swallow, from 20-30 gr. (1.3-2.0 gm.) of chloral may be 
injected into the rectum. If these measures fail, morphin may 
be used cautiously (see p. 97). 

Nausea and Vomiting. — When these symptoms persist food 
should be withheld. Pieces of ice may be given to suck. A 
mixture containing bismuth subnitrate and diluted hydrocyanic 
acid (see p. 161) often affords relief. Carbolic acid, wine of 
ipecac, or tincture of nux vomica, in one-drop doses, may be 
tried. 

Anemia. — After the acute symptoms have subsided iron may 
be employed to combat the anemia. For adults Basham's 
mixture is a suitable preparation. Of this from 2-4 fl. dr. 
(8.0-15.0 c.c.) may be given thrice daily. For children the 
following mixture will be found more agreeable : 

R Tincturae ferri chloridi; 

Acidi phosphorici diluti, da fgiss (6.0 c.c.) ; 

Glycerini, fzvj (22.5 c.c.); 

Syrupi acidi citrici, q. s. ad f^iij (90.0 c.c). M. 

Sig. — Teaspoonful in water three times a day. 

Convalescence. — It is advisable to keep the patient under 
observation for many weeks after all symptoms of the disease 
have disappeared. He should be warmly clad and carefully 
guarded from exposure to wet and cold. While the diet 
should be liberal it should be such as will not overtax the 
kidneys. Overexertion must be rigidly avoided. The skin 
and bowels should be kept active, the former by frequent tepid 
baths and the latter by saline aperients if necessary. A change 
of air to a warm, equable climate will be found to be very 
beneficial. 

CHRONIC NEPHRITIS. 

The indications for treatment in chronic nephritis are to 
lessen the work of the kidneys by reducing the production of 
nitrogenous waste and increasing the activity of the other 
excretory organs, to maintain the general nutrition, and to 
meet the symptoms as they arise. The patient must be 
guarded against vicissitudes of weather by wearing flannel 
next to the skin in all seasons, both night and day. If he can 
afford it he should be urged to spend the winter months in a 
warm, equable climate. 



DISEASES OE THE KIDNEYS. 619 

In the absence of any obtrusive symptoms, moderate exer- 
cise short of fatigue should be encouraged, but all violent 
exertion should be prohibited. Mental strain and worry are 
also injurious, and should be avoided as far as possible. When 
the symptoms are well developed rest becomes an important 
factor in the treatment, and much time should be passed in 
bed. The use of tobacco and alcohol should be discontinued. 
Warm baths with friction are necessary to promote free action 
of the skin, but great care must be exercised after their use to 
avoid chilling. In the early stages of chronic interstitial neph- 
ritis an occasional Turkish bath is often very advantageous. 
The hot-air bath, vapor bath, or hot pack may be used at home 
once or twice a week, or oftener if there is much edema, or if 
uremia threaten. Cold bathing should be interdicted. The 
bowels should be kept active by an occasional saline aperient. 
A great deal depends upon diet. No hard-and-fast rules, how- 
ever, can be laid down, each case being a study in itself. When 
the symptoms are quiescent, a simple nourishing diet compris- 
ing a moderate quantity only of nitrogenous matter, may be 
allowed, its effect on the urine being carefully watched. Green 
vegetables, potatoes, farinaceous food, and ripe fruits usually 
agree best, but a certain amount of animal food in the form of 
eggs, oysters, fish, and mutton, or other tender meats, is often 
well borne. Indeed, considerable caution must be exercised 
lest in our zeal to relieve the kidneys we reduce the strength of 
the patient by adhering too strictly to a non-nitrogenous diet. 
The common dogma that red meats are more harmful than white 
meats in chronic Bright's disease receives no support from the 
observations of von Noorden, Offer and Rosenquist, or KaufT- 
mann and Mohr, who conclude that the various forms of meats 
are suitable in such cases purely in proportion to their digesti- 
bility. Water-drinking between meals is generally beneficial, 
and a mild alkaline mineral water, such as Vichy or Vals, may 
be taken to the extent of a pint (0.5 L.) or more a day. In 
many cases of chronic parenchymatous nephritis, especially 
when there is decided edema or a tendency to uremia, an 
absolute milk diet is most suitable. The patient should take 
at stated intervals such quantities of milk as will aggregate in 
the twenty-four hours from 2-4 quarts (2.0-4.0 L.). The 
milk should not be skimmed, but diluted with carbonated water 
or an alkaline mineral water. 

In chronic interstitial nephritis an absolute milk diet is not 
always successful. Indeed, as von Noorden has pointed out, 
much good sometimes results from restricting in this form of 
nephritis the fluids to between 40 and 50 ounces (1200.0- 



620 APPLIED THERAPEUTICS. 

1 500.0 c.c), especially when there is dilatation of the heart and 
a tendency to cardiac asthma. 

Medicinal Treatment. — We possess no remedies that are 
directly curative. In the interstitial form potassium iodid 
(1-5 gr. — 0.06-0.3 gm.) or bichlorid of mercury ( 6 V ~~ A g r - — 
0.001-0.0016 gm.), two or three times a day, occasionally 
seems to have a beneficial effect, but in the large majority of 
cases these remedies are of no avail. Mild hematinics, like 
Basham's mixture, are often useful, especially in chronic paren- 
chymatous nephritis, but only small doses should be used. 
The indiscriminate use of iron in chronic interstitial nephritis, 
as Tyson has shown, is often productive of harm. It is indi- 
cated only when there is evident anemia. Strychnin and the 
simple bitters are valuable adjuvants to iron in many cases. 
Late in the disease, when the urine becomes scanty and dropsy 
appears, hydragogue diuretics are called for, although they 
often prove disappointing. Those most likely to succeed are 
digitalis, the vegetable salts of potassium, carTein, and theo- 
bromin. 

Operative Treatment. — Edebohls claims that chronic 
Bright's disease in its early stages is curable or susceptible 
to amelioration by renal decapsulation. The good results of 
the operation are attributed to the development of numerous 
blood-vessels, particularly arteries, in the firm adhesions be- 
tween the kidneys and the surrounding tissues, the blood 
stream passing from the latter to the kidneys. This, it is 
thought, leads to gradual absorption of the intertubular inflam- 
matory products, thus freeing the tubules and glomeruli from 
compression, and permitting the re-establishment of a normal 
circulation, with regenerative production of new epithelium 
capable of carrying on the secretory function. Edebohl's 
operation has not been employed extensively enough as yet to 
warrant positive conclusions as to its therapeutic value. That 
it has resulted in marked improvement in some cases must be 
admitted ; that actual cure has ever been effected by it, how- 
ever, is extremely doubtful. 

Treatment of Special Symptoms. — For the anemia the 
most effectual measures have already been enumerated (see 
p. 618). 

Dropsy. — Hydragogue cathartics and hot-air baths are chiefly 
to be relied upon for abstracting the water from the body. 
Among the former, Epsom salt, compound jalap powder, and 
elaterium are the most serviceable. Injections of pilocarpin 
may also prove useful, but they should be withheld when the 



DISEASES OF THE KIDNEYS. 621 

heart is weak or when there is any tendency to pulmonary 
edema. Diuretics are sometimes efficacious. The best are 
digitalis, the vegetable salts of potassium (bitartrate or acetate), 
caffein, theocin, and theobromin. The dechloridation treatment 
of Widal and Javal is at times very successful and is well 
worth trying. It consists in giving food with a minimum 
amount of salt. When dropsy is extreme and does not yield 
to the usual remedies, operative measures may be required 
(see p. 617). 

High Blood-pressure. — A certain increase in the arterial 
tension is necessary. It compensates for the renal inadequacy. 
When, however, the tension in the vessels becomes excessive 
and gives rise to headache, vertigo, palpitation, and dyspnea, it 
should be reduced by saline laxatives, warm baths, and the 
administration of nitroglycerin (yj-g- gr. — 0.00065 gm. — three 
times a day, increased if necessary until the desired effect is 
accomplished). 

Heart-failure with low arterial tension will require the use 
of such stimulants as digitalis, strychnin, caffein, and alcohol. 

Asthma should be treated as a manifestation of uremia. 
Nitrite of amyl, nitroglycerin, or ethyl nitrite affords some re- 
lief. When there is pulmonary congestion or edema, dry or 
wet cupping is often useful. 

Insomnia may be caused by the retention in the blood of 
excrementitious matter, or may be due to high arterial tension. 
In the first case a milk diet and the administration of elimi- 
nants are called for ; in the second, vasodilators (nitroglycerin 
or erythrol tetranitrate) will be helpful. When the insomnia 
is sufficiently severe to demand the use of hypnotics, bromids, 
veronal, chloral, paraldelyd, and trional may be tried in the 
order named. Opium should be avoided. 

Headache is best treated by cold to the head, and the ad- 
ministration of saline purges and caffein (2-3 gr. — 0.13-O.2 gm.) 
or nitroglycerin (1-2 min. — 0.06-0.12 ex.). 

Vomiting. — When vomiting is persistent it is best to with- 
hold food entirely for a time, allowing carbonated water or 
cracked ice only by the mouth. Sinapisms over the epigas- 
trium sometimes afford relief. Such gastric sedatives as 
diluted hydrocyanic acid, bismuth subnitrate, cocain, and 
oxalate of cerium are worthy of trial. 

Diarrhea should not be checked too quickly. When treat- 
ment is desirable mild astringents and intestinal antiseptics 
may be given. Opium should be used with extreme caution, 
if at all, not only in this but in all other complications of 
chronic nephritis in which sedatives are indicated. 



622 APPLIED THERAPEUTICS. 



NEPHROLITHIASIS. 



Medical treatment should be given a thorough trial in all 
cases of suspected renal calculus. It is doubtful whether 
stones once formed in the pelvis of the kidney can ever be 
dissolved, especially if they have already attained a consider- 
able size, but much can be accomplished by internal remedies 
in preventing the formation of fresh deposits and in mechan- 
ically washing down into the bladder small concretions. 

As uric-acid calculi are by far the commonest, efforts should 
be directed toward lessening the formation of uric acid and 
preventing its precipitation in the urinary passages. The 
patient should use only those articles of food which experience 
has shown to be most easily digested. The foods most likely 
to disagree are concentrated soups, hashes, croquettes, pastry, 
sweets, acid fruits, malt liquors, heavy wines, and all articles 
rich in nucleins, like the internal organs and young germi- 
nating plants. The quantity as well as the character of 
the food must be regulated. No more should be eaten 
than is absolutely necessary to maintain normal nutrition. 
Too long an interval should not be allowed to elapse be- 
tween meals. 

Gentle exercise in the open air and hydrotherapy are to be 
recommended since they favorably affect the underlying diath- 
esis. 

Much benefit accrues from abundant water-drinking between 
meals. This not only favors the expulsion of small concre- 
tions from the kidney, but by diluting the urine it also tends 
to prevent the precipitation of uric acid. Alkaline mineral 
waters, like Carlsbad, Vichy, Vals, and Buffalo and London- 
derry lithia waters have been extensively employed, but they 
are no more efficacious than plain water which has been ren- 
dered alkaline by the addition of potassium citrate, J— I dr. 
(2.0-4.0 gm.) to the quart (1.0L), or of potassium bicarbonate, 
40 grains (2.5 gm.), and lithium citrate, 20 grains (1.3 gm.), to 
the quart. About a quart of such water should be consumed, 
as a rule, in the twenty-four hours. In mild cases a single 
copious draught at bedtime may suffice to prevent recurrence 
of colicky pains. Some care is necessary not to allow the 
urine to become too alkaline, since this may lead to a deposi- 
tion of phosphates about the uric-acid stone. 

Among special remedies brought forward as solvents of uric 
acid (see p. 243) may be mentioned piperazin, lycetol, lysidin, 
piperidin tartrate, and urosin. While some authors claim to 
have seen beneficial effects follow the use of these drugs, the 



DISEASES OF THE KIDNEYS. 623 

majority of unprejudiced observers are sceptical as to their 
merits. 

Recently Croftan has recommended calcium carbonate 
(15-20 gr. — 1. 0-1.3 g m - — thrice daily), which was first advo- 
cated by Von Noorden. The theory is that calcium, owing to 
its great affinity for phosphoric acid, unites with this acid in 
the blood to form calcium phosphate, which is subsequently 
eliminated in great part through the bowel, thus ridding the 
urine of mono-sodium phosphate, a precipitant of uric acid, 
while leaving in the urine di-sodium phosphate, an active sol- 
vent of uric acid. 

Phosphatic Calculi. — Since phosphatic calculi can be depos- 
ited only from alkaline urine the indication is to render the 
urine acid, a task often difficult of accomplishment. Instead of 
a vegetable diet, one composed largely of readily digestible 
proteids should be ordered. Among special remedies recom- 
mended for the purpose of acidifying the urine may be men- 
tioned benzoic and boric acids. From 5-15 gr. (0.3-1.0 gm.) 
of either of these drugs may be given in capsule, three to four 
times a day. Unfortunately, the continued use of these acids 
is prone to cause indigestion, an effect which detracts mate- 
rially from their value. As in the case of uric-acid concre- 
tions, the copious ingestion of plain or distilled water is to be 
encouraged in order to prevent concentration of the urine. 

Oxalate-of-lime Calculi. — As there is reason to believe that 
oxalates are formed under conditions very similar to those 
which give rise to an excess of uric acid, what has been said 
concerning the treatment of the uric-acid diathesis applies 
equally to that of the oxalate of lime. 

Renal Colic. — The indications are to relieve the pain and 
to relax the spasm. This is best accomplished by hypodermic 
injections of morphin and atropin, coupled with hot baths or 
local applications — hot poultices or fomentations. If the pain 
is extreme it may be desirable to administer chloroform. 
Simple diluents should be given freely. In mild attacks full 
doses of phenacetin or antipyrin, with an abundant supply of 
hot drinks, may suffice. 

Surgical Treatment. — In a certain number of cases sur- 
gical intervention affords the only hope of permanent relief. 
Operation is urgently demanded when the attacks of renal colic 
occur with such frequency as to prove disabling, when there 
are evidences of severe pyelitis, and when there is reason to 
believe that the calculus is impacted in the ureter. Unless 
there be pyonephrosis, nephrolithotomy is the operation to be 



624 APPLIED THERAPEUTICS. 

recommended, as it is attended with much less risk than that 
of nephrotomy or nephrectomy. The mortality in 82 cases of 
nephrolithotomy for non-suppurative nephrolithiasis was 2.4 
per cent. (Newman and Legue). The average mortality in 
suppurative cases is not less than 15 per cent. The low mor- 
tality of early operation contrasted with the high mortality of 
late operation, when the kidney structure has been seriously 
damaged, is a strong argument for early interference. 

DISEASES OF THE NERVOUS SYSTEM, 

ACUTE CEREBRAL LEPTOMENINGITIS. 

The treatment should be conducted on the same lines as 
that of cerebrospinal fever (see p. 515). When middle-ear 
disease is the exciting factor, and the symptoms can be defi- 
nitely localized, operation may be justifiable. Several writers 
have recently spoken favorably of frequently repeated warm 
baths, as originally recommended by Aufrecht in 1894, com- 
bined with lumbar puncture (see p. 507). 

CEREBRAL HEMORRHAGE. 

Prophylaxis. — Patients predisposed to apoplexy should 
lead a quiet life, one as free as possible from mental and phys- 
ical excitement. The food should be nutritious and easily 
digestible. Moderation in eating and regularity of meals are 
matters of prime importance. Alcohol should be interdicted. 
The bowels should be made to act daily, a mild aperient being 
given if necessary. 

The Attack. — If the patient be seen early, he should be 
placed in a reclining position with the head and shoulders well 
elevated. Bowles advocates turning the patient over on the 
paralyzed side to lessen the stertor. An ice-bag should be 
applied to the head, and warm bottles to the feet. The bowels 
should be promptly emptied by an enema, and later by a 
drastic cathartic, preferably croton oil, one or two drops of 
which, mixed with a little sweet oil, may be placed upon the 
tongue. 

In sthenic cases, when the face is congested and the pulse 
is slow and full, venesection to the amount of \~\ pint (250.0- 
500.0 c.c.) is indicated. The abstraction of blood cannot undo 
damage that is already done, but by lessening the supply of 
blood to the brain it may serve to arrest bleeding that is still 
in progress or to prevent an early recurrence. If venesection 
does not seem justifiable, lowering of the arterial pressure may 
be effected by the administration of aconite or veratrum viride. 



DISEASES OF THE NERVOUS SYSTEM. 625 

When the heart's action is feeble and the face is blanched, 
stimulants like alcohol, ether, and camphor may be given very 
cautiously, although it is unlikely that they will be of much 
avail. 

When the respiration fails before the circulation, artificial 
respiration may be practised with advantage. In a case cited 
by H. C. Wood, in which final recovery was complete, it was 
necessary for nearly two days for an attendant to hold forward 
the jaw and tongue by raising the ramus of the jaw upward 
and forward, in order to prevent mechanical asphyxia. 

Thorough cleanliness, bathing with alcohol, frequent change 
of position, and the avoidance of roughnesses in the bed are 
necessary in order to prevent the development of bed-sores. 
Since blisters are produced more readily than in health, special 
care should be taken in using hot applications of any kind. 

Retention of urine is apt to occur, and if it does the patient 
must be catheterized. 

After the Seizure. — Absolute rest in bed must be main- 
tained. Even in the mildest cases the patient should not be 
allowed to leave his bed for two or three weeks, and during 
this time the diet should be light and unstimulating. The ice- 
cap should still be kept upon the head. Aconite in small 
doses with sweet spirits of nitre is often useful in subduing the 
fever of reaction and in decreasing arterial tension. For rest- 
lessness and wakefulness, small doses of a bromid or of chlo- 
ral may be given. Potassium iodid is often prescribed with the 
hope that it may aid in absorbing the clot, but it is of doubtful 
utility, and moreover, it is very prone to disturb the digestion. 

After the acute symptoms have entirely disappeared, which 
will rarely be earlier than ten days or two weeks after the 
attack, massage should be systematically practised. It often 
contributes much to the restoration of power, or when this is 
impossible, to the prevention of contractures. After the lapse 
of three or four weeks, triweekly applications of the faradic 
current may be of service (see p. 481). Strychnin is often 
given at this time, but it probably exerts no other influence 
than that of a general tonic. In some cases warm saline baths 
(90°-95° F. — 32°-35° C), combined with passive movements, 
prove useful adjuvants. 

LOCOMOTOR ATAXIA. 

Rest is an important factor in the treatment. The sense of 
fatigue being impaired in this disease, patients are very prone to 
overtax their strength. Erb advises that the patient should 
live as if he were an old man, quietly, regularly, and with no 
excitements. In many cases it is well to begin treatment with 

40 



626 APPLIED THERAPEUTICS. 

absolute rest in bed for several weeks. Mental fatigue should 
also be avoided. Sexual excesses are exceedingly injurious. 
The diet should be nutritious and easily digestible. Alcohol 
and tobacco should be used sparingly, if at all. 

Patients suffering from locomotor ataxia should wear flannel 
next to the skin, and should avoid exposure to wet and cold, 
as well as sudden alterations of temperature. When practi- 
cable a change to a warm, equable climate during the winter 
months may be recommended with advantage. 

Massage affords a valuable means of securing the benefits of 
exercise without the expenditure of energy. 

Systematic re-education of co-ordinating movements, as 
originally recommended by Frenkel, has been found a most 
effective remedy for the ataxia (see p. 486). Even in advanced 
cases, in which there is marked disturbance of sensation, this 
method of treatment is not without benefit, and the improve- 
ment may last for years if the disease is stationary or only 
slowly progressive. The treatment by suspension, introduced 
by Motschukowski, and that by nerve-stretching, proposed by 
Langenbuch, have become obsolete. 

Tepid baths of 8o°-85° F. (26.^-2^° C.) are sometimes 
of distinct service. On the other hand, hot baths, vapor baths, 
and cold baths are usually harmful, and often provoke lanci- 
nating pains. Various natural springs enjoy a special reputa- 
tion, the most popular being the Hot Springs of Arkansas, 
those of Virginia, and those of Los Vegas, New Mexico, in this 
country, and the thermal baths at Rehme, Nauheim, and Aix- 
la-Chapelle in Europe. Patients in whom the disease is far 
advanced should, of course, be spared the cost and discomforts 
attendant upon a long journey. According to Frenkel, treat- 
ment by baths should be forbidden while the exercise treatment 
is being used. While electricity is undoubtedly of service in 
relieving certain sensory disorders of ataxia, there is no ground 
for believing that it can affect in the slightest degree the mor- 
bid process in the spinal cord. 

Mercury and iodids should be given a thorough trial in all 
cases in which syphilis is suspected. It must be admitted, 
however, that antisyphilitic treatment rarely accomplishes any 
good unless the infection by syphilis has been quite recent. 
Most of the cases of tabes that have recovered under mercury 
have been examples of peripheral neuritis. 

Among numerous special remedies which have been in vogue 
at various times, but which are of very doubtful utility, may be 
mentioned silver nitrate, ergot, calabar bean, strychnin, bella- 
donna, phosphorus, chlorid of gold, arsenic, corrosive subli- 
mate, and spermin. 



DISEASES OF THE NERVOUS SYSTEM. 627 

Treatment of Special Symptoms. — When the pains are 
severe the most potent remedial measure is absolute rest in 
bed. Light touches of the actual cautery or sinapisms over 
the root of the nerve supplying the affected part often afford re- 
lief. Deep massage is sometimes of service. Mitchell has found 
the alternate application of ice and hot water useful. Flannel 
bandages applied firmly from the toes up to the middle third 
of the thigh sometimes do much good. A snugly fitting 
abdominal binder may also be used to lessen girdle pain. 
Electricity in the form of the faradic brush, static spark, or 
stabile galvanic anode, is worthy of a trial. 

The most generally useful anodynes are phenacetin, anti- 
pyrin, and acetanilid. Cannabis indica occasionally succeeds. 
According to Osier, the prolonged use of nitroglycerin, given 
in increasing doses until the physiologic effect is produced, is 
of great service in allaying pains and diminishing the frequency 
of crises in all cases of tabes in which there is increased arte- 
rial tension. In many cases recourse must be had to morphin, 
but its use should be deferred as long as possible. 

Gastric Crisis may require the withholding of food by the 
mouth for a time, the patient being sustained by nutritive 
enemata. Lavage is often beneficial. The application of sina- 
pisms over the epigastrium may do good. Morphin hypoder- 
mically may be necessary. 

Laryngeal crisis may be relieved by local applications of 
cocain, inhalations of chloroform or amyl nitrite, or the admin- 
istration of anodynes. 

Numbness and paresthesia often yield for a time to local 
applications of faradism given with the wire brush. 

Vesical and rectal tenesmus may be relieved by suppositories 
of opium with belladonna, or applications of cocain. Mitchell 
has found faradism of great service (see p. 482). 

Obstinate priapism is best treated by tepid hip-baths or gen- 
eral baths and the administration of anaphrodisiacs — bromids, 
monobromated camphor, or hyoscin. Sexual intercourse 
should be avoided. 

Vesical weakness should receive the most careful attention. 
The bladder must be thoroughly emptied, if need be by cathe- 
terization. On the first appearance of cystitis the bladder 
should be thoroughly washed out with weak antiseptic solu- 
tions. 

MYELITIS. 

Acute Myelitis. — No time should be lost in placing the 
patient at absolute rest. In severe cases a water-bed should 
be employed. Such antiphlogistic measures as cupping, blis- 



628 APPLIED THERAPEUTICS. 

tering, and cauterizing are of doubtful utility. Cold, however, 
in the form of Chapman's ice-bags, may be applied to the 
spine. Daily warm baths (90 F. — 3 2.2 ° C.) lasting from ten to 
fifteen minutes are useful. Drugs are of little value. Ergot is 
often used for the purpose of constricting the spinal vessels 
and thus limiting the local congestion. 

Every precaution must be taken against the development of 
bed-sores. Frequent change of the patient's position, absolute 
cleanliness of the parts subjected to pressure, and bathing with 
alcohol and water will do much toward obviating this com- 
plication. If bed-sores are already formed they should be 
treated thoroughly according to surgical principles. Retention 
of urine must be met by systematic catheterization under the 
most strict antiseptic precautions. When there is constant 
incontinence a carefully adjusted urinal should be employed. 

Any tendency to cystitis will call for daily irrigation of the 
bladder with a solution of boric acid or other mild antiseptic 
solution. If recovery with partial paralysis result, massage 
and electricity may aid in bringing back some of the lost 
power. 

Chronic Myelitis. — Hygienic measures are far more im- 
portant than drugs. Prolonged rest is desirable. Residence 
in a warm, equable climate is often serviceable. Daily warm 
baths are grateful. Counterirritation in the form of light 
touches of the actual cautery is useful in relieving pain, but it 
does not seem to exert any direct influence on the progress of 
the disease. When there is reason to suspect the existence of 
syphilis, mercury and iodids should be given a thorough trial. 
Tonics*are often indicated. Massage, passive movements, and 
electricity are useful in maintaining the nutrition of the affected 
muscles. Early measures should be taken to prevent the 
formation of bed-sores and the development of cystitis. 

POLIOMYELITIS. 

Acute Poliomyelitis. — In the acute stage absolute rest in 
bed is requisite. Not the slightest benefit accrues from the 
application of wet cups or leeches to the spine, or from any 
other form of counterirritation. Mild mercurial laxatives and 
febrifuge medicines may be used with some advantage. Ergot 
is often prescribed for the purpose of diminishing congestion 
of the ventral horns, but it is of very doubtful utility. The 
affected limbs should be thoroughly wrapped in cotton-wool to 
maintain warmth and circulation. 

After the acute symptoms have subsided, which will prob- 
ably be at the end of two or three weeks, an effort should be 
made to promote the restoration of the paralyzed muscles. 



DISEASES OF THE NERVOUS SYSTEM. 629 

General hygienic measures must not be neglected. Nutritious 
food and fresh air are valuable aids. Little is to be expected 
from internal medication. Tonics like iron and cod-liver oil 
are sometimes of service. Strychnin seems to do some good. 
Massage in the form of effleurage and kneading is the most 
useful measure. It should be practised for ten or fifteen 
minutes daily for several months, or even for a year. Local 
bathing with shampooing may also be employed with 
benefit. 

Electricity, while less efficacious than massage, is worthy of 
a thorough trial. As faradism generally fails to elicit any re- 
sponse, recourse must be had to an interrupted galvanic cur- 
rent. One pole (cathode) may be placed over an indifferent 
point, such as the spine, while the other (anode) is slowly 
stroked over the affected muscles. The weakest current that 
will cause contraction should be used. The treatment should 
be given for ten minutes, three or four times weekly, and should 
be kept up, if necessary, for several months. If after six or 
eight weeks of electric treatment there is no demonstrable im- 
provement the outlook is very gloomy. Still, even here a 
successful issue is not impossible. The treatment of the later 
stages of infantile paralysis is chiefly surgical, and has for its 
object the prevention or correction of deformities. 

Chronic Poliomyelitis. — There is practically no remedy 
for this disease. Massage, hydrotherapy, and electricity have 
seemed to be of some avail, but no permanent good has been 
achieved by these or other measures. Gowers has spoken 
favorably of strychnin and arsenic. In cases with a history of 
syphilis, mercury and iodids should be tried. 

NEURITIS. 

Careful search should be made for the exciting cause — rheu- 
matism, gout, syphilis, alcoholism, metallic poisoning, mechan- 
ical injury, or neighboring inflammation — with the view of 
removing it if possible. Absolute rest is imperative. When 
the nerves of the limbs are affected the muscles should be im- 
mobilized by means of splints and bandages, as in the treatment 
of fracture. 

In acute cases, irrespective of the cause, counterirritation is 
of service. This may be accomplished by applying linear blis- 
ters or painting iodin along the course of the inflamed nerve. 
In mild forms of the disease hot applications of lead-water and 
laudanum will suffice. Occasionally cold in the form of an 
ice-bag proves more grateful than fomentations. Coal-tar 
derivatives (phenacetin, antipyrin) and salicylates are useful in 



63O APPLIED THERAPEUTICS. 

relieving pain. Such combinations as the following are often 
efficacious : 

& Acetphenetidini, giss (6.0 gm.) ; 

Salol, 3J (4.0 gm.). — M. 
Fiant chartulae, No. xii. 
Sig. — One every three or four hours. 

R Codeinse sulphatis, gr. iij (0.2 gm.) ; 

Acetanilidi, 

Salophen, aa £j (4.0 gm. ) . — M. 

Fiant chartulae, No. xii. 
Sig. — One every three or four hours. 

When the pain is very intense subcutaneous injections of 
morphin must be used. 

As soon as the pain and tenderness have distinctly lessened 
warm baths and gentle friction may be employed. In localized 
neuritis inunctions with mercury and belladonna ointment may 
also be used with great advantage in this stage. When the 
symptoms of irritation have completely subsided massage and 
electricity should be resorted to for the purpose of restoring 
the functions of the nerves and muscles. The faradic current 
should be used if the muscles respond to it. In the more 
severe cases in which faradic excitability is lost, labile and 
interrupted galvanic currents should be applied with the pole 
that produces the best contractions. Even with extreme 
atrophy these measures sometimes succeed in effecting decided 
improvement. Passive movements and extension will be 
required to overcome contractures and deformity. 

Tonics, especially strychnin and arsenic, are often of service 
in the later stages of the disease. 

Sciatica. — The first indication is to remove the cause. 
This may be some affection of the pelvic organs requiring sur- 
gical intervention, or it may be rheumatism, gout, syphilis, or 
metallic poisoning, and then general as well as local treatment 
must be resorted to. 

In acute cases rest in bed is essential. Free evacuation of 
the bowels should be secured in order to deplete the pelvic 
veins. When there is a definite history of rheumatism or the 
attack has been induced by cold, salicylates should be given in 
full doses. When there is reason to suspect syphilis iodids 
should be given a fair trial. Irrespective of the cause, phe- 
nacetin or antipyrin may be useful in relieving pain. Counter- 
irritation often affords much relief. When the pain is very 
severe this is best accomplished by means of small blisters or 
light touches of the actual cautery applied over the points of 
greatest tenderness. In some cases acupuncture (see p. 43 8 J 
acts very satisfactorily. In milder cases the Scottish douche — 



DISEASES OF THE NERVOUS SYSTEM. 63 1 

in which a stream of warm water of gradually increasing tem- 
perature is directed on the course of the nerve until the pain 
subsides, when it is suddenly changed for a cold jet — is an 
efficient remedy. Agonizing pain must be relieved by injec- 
tions of cocain (} gr. — 0.016 gm.), chloroform (5-10 min. — 
0.3-0.6 c.c), guaiacol (2-3 min. — 0.1-0.2 c.c), or morphin 
(|— J- gr. — 0.008-0.016 gm.), made deeply and as near to the 
nerve as possible. Morphin should be withheld as long as 
possible on account of the grave danger of inducing the mor- 
phin habit. In some cases deep injections of distilled water 
act remarkably well. Massage is indicated only when the 
acute symptoms have subsided, and should then not be too 
energetic. Electricity is rarely needed, even if there has been 
much wasting. In obstinate cases of sciatica the following 
treatment, outlined by S. Weir Mitchell, often acts most hap- 
pily : A long flannel bandage is firmly applied from the foot 
to the groin, and renewed twice a day. The leg is slightly 
bent at the knee and kept nearly straight at the thigh, and in 
this position secured to a light side splint extending from the 
axilla to the ankle by a few turns of a bandage. Care is of 
course taken to prevent pressure on the heel. After a few 
days the joint-angles are slightly changed at each dressing. 
Still later passive motion is carefully employed, and after about 
three or four weeks the splint is removed during the day and 
replaced at night. Finally, guided as to time by the presence 
or absence of pain, the splint is removed altogether, the band- 
age being kept on somewhat longer, and gentle massage being 
used between each application after pain has quite disappeared. 
A full diet, cod-liver oil, and iron as needed, are given during the 
whole period. Any points of persistent pain that may be left 
at the close of the treatment are treated by counterirritants, 
preferably by small blisters or light touches of a white-hot 
Paquelin button. The patient must not sit at all during the 
first week after getting up, but must stand or walk, and that 
only with crutches. He may be upright or lying on a bed, but 
not seated. 

Among other measures which have proved successful in 
individual cases may be mentioned hydrotherapy in the form 
of warm baths or mud baths, galvanism (5-7 milliamperes), 
the continued application of ice-bags, and nerve-stretching, 
either by forcibly flexing the thigh upon the body or by cut- 
ting down upon the nerve itself. 

NEURALGIA. 

An effort should be made to adapt the treatment to the eti- 
ology of the disease. Causes of reflex irritation — carious 



632 APPLIED THERAPEUTICS. 

teeth, errors of refraction, nasal obstruction, neoplasms, and 
cicatrices — should be sought for, and when found removed if 
possible. When the disease is associated with anemia, iron 
and arsenic will be indicated. If there is any suspicion of 
syphilis, mercury and iodids should be tried. When a malarial 
element is present, quinin may effect a cure. When rheuma- 
tism is an etiologic factor, salicylates and alkalis may prove 
beneficial. In gouty subjects much may be expected from 
regulation of diet, systematic exercise, and the administration 
of alkalis. The occupation of the patient, a blue line on the 
gums, and lead in the urine may lead to the recognition of 
plumbism, and in this case the iodids will be indispensable. 

All influences that tend to induce a morbid excitability of 
the nerves or of their centers — mental or physical fatigue, 
emotional excitement, sexual excess, over-indulgence in 
tobacco, tea, coffee or alcohol — should be removed so far as 
possible. 

In every case of neuralgia we must endeavor to improve the 
general nutrition, which is almost always disturbed. The 
measures to be employed for this purpose include an abun- 
dance of fresh air, proper food, regular hours, adequate pro- 
tection from the vicissitudes of weather, systematic exercise, 
frequent bathing with friction, and the use of such tonics as 
iron, arsenic, cod-liver oil, and hypophosphites. If the patient 
cannot take active exercise rest with massage should be sub- 
stituted. Neuralgia in neurasthenic patients is sometimes 
successfully managed by a modified Weir Mitchell treatment. 
A change of residence to a warm dry climate has been known 
to effect a complete cure. 

Special Treatment. — The list of agents recommended for 
the cure of neuralgia is bewildering. " Numerous are the 
means at our disposal for combating the disease, quite as 
numerous are the patients who, after hundreds of unsuccessful 
trials, give up all medicines and all physicians " (Hirt). Among 
the internal remedies most worthy of confidence may be men- 
tioned the coal-tar analgesics (phenacetin, antipyrin, and ace- 
tanilid), morphin, bromids, cannabis indica, croton chloral, 
gelsemium, cafTein, nitroglycerin, and salicylates. The coal-tar 
analgesics are the most generally useful anodynes for the 
attack. Their action, moreover, is prompt. From 5-8 gr. 
(0.3-0.5 gm.) of one of these drugs may be given every two or 
three hours, according to the intensity of the pain. The fact 
must be borne in mind that these agents when used contin- 
uously not only lose in potency, but may also unfavorably 
influence general nutrition. Morphin is undoubtedly the most 
certain means we possess of affording temporary relief, but on 



DISEASES OF THE NERVOUS SYSTEM. 633 

account of the danger of inducing the opium habit it should 
be employed only as a last resort. Under no circumstances 
should the patient himself be allowed to use the hypodermic 
syringe. In mild attacks bromids in large doses sometimes 
succeed. Combinations of a bromid with phenacetin or anti- 
pyrin may often be prescribed advantageously. Cannabis 
indica is especially valuable in migraine, in which affection it 
may be given in doses of from J— J gr. (0.0 1 6-0.03 gm.). Cro- 
ton chloral, in . doses of from 5-10 gr. (0.3-O.65 gm.), and 
tincture of gelsemium, in doses of 10 min. (0.6 c.c.) or more, 
are occasionally serviceable in trifacial neuralgia. Caffein, in 
doses of from 3-5 gr. (0.2-0.3 gm.), is often efficacious. Com- 
binations of caffein with phenacetin or with bromids in many 
cases do more good than single drugs. Nitroglycerin, in doses 
of from 1 1 * gr. (0.0004-0.0012 gm.), has been highly 
recommended in migraine-like attacks with signs of vasocon- 
constriction. Neuralgia brought on by exposure to cold and 
wet is favorably influenced by the salicylates. In such the 
following combination will be found of value : 

R Acetphenetidini, 

Salophen, aa giss (6.0 gm.) ; 

Codeinse sulphatis, gr. iij (0.2 gm.). M. 

Fiant chartulse, No. xii. 
Sig. — One powder every two or three hours. 

Dana and others have spoken favorably of strychnin in 
heroic doses in tic douloreux (see p. 145). 

I/OCal Treatment. — Heat, dry or moist, may be applied 
for its soothing effect. In some cases cold in the form of an 
ice-bag is more grateful. Menthol and chloral camphor are 
useful in neuralgia of superficial nerves when the pain is slight. 
Congelation of the skin by ethyl chlorid occasionally has a good 
effect. Acupuncture and aquapuncture are effective, but are 
not suitable for use about the face. In obstinate cases active 
counterirritation by means of blisters or the thermocautery 
will be found a potent remedy. In trifacial neuralgia the blis- 
ters may be applied behind the ear. Even when the pain is 
very intense injections of cocain (-§-— j gr. — 0.008-0.0 1 6 gm.) 
upon the nerve often bring relief, but the grave danger of 
establishing a habit must never be forgotten. Cocain may also 
be introduced through the unbroken skin by cataphoric action 
(see p. 482). Electricity is sometimes of service. Bennett and 
Hammerschlag have each treated 9 cases of trifacial neuralgia 
by the injection of osmic acid into the nerve with good results. 
Schlosser, Oswalt, Kiliani, and others report favorably upon 
deep injections of alcohol. No matter what agent is employed, 



634 APPLIED THERAPEUTICS. 

however, treatment by injection rarely affords relief for more 
than a year or two. 

Finally, when all other measures fail, recourse may be had 
to surgical interference. Nerve-stretching and nerve-section 
are the operations usually performed. Lasting benefit is rarely 
obtained from either operation, although excision is more re- 
liable than stretching. In trifacial neuralgia removal of the 
Gasserian ganglion or division of its sensory root usually affords 
permanent relief. In the last few years the mortality of this 
procedure has been much reduced. In Horsley's series of 120 
cases it was 3.3 per cent., and in 27 cases reported by Frazier 
it was 3.7 per cent. 

CHOREA. 

Rest of body and mind is the most important factor in the 
treatment of the disease. No matter how slight the attack 
may be the child should be taken from school. In all except 
the mildest cases rest in bed in a quiet, well-ventilated room is 
essential. When the movements are so violent as to bring 
about contusions the bed should be padded or the child put in 
a hammock. It is almost always advisable to exclude the 
child's playmates, even his own brothers and sisters, from the 
sick-room. Excitement of all kinds should be proscribed. 

Gentle massage may be of benefit, especially in poorly 
nourished children, but gymnastic exercises should be reserved 
for the period of convalescence. Daily warm baths (95 F. — 
35 C.) are often beneficial. In older children, and especially 
in neurotic cases, the wet-pack may be used with great advan- 
tage. As M. Allen Starr has pointed out, a change of air, 
especially a change to the seashore, is often of the utmost ser- 
vice in obstinate cases. 

In all cases of chorea reflex irritation — ocular defects, adher- 
ent prepuce, etc. — should be carefully sought for, and when 
found removed if possible. On account of the tendency of 
chorea to recur, children who have once suffered from the dis- 
ease should not be overtaxed in school, and should be guarded, 
as far as possible, from attacks of rheumatism. 

Medicinal Treatment. — Arsenic is by far the most useful 
remedy. The dose should be gradually increased until physi- 
ologic effects are produced. In a child of five or six years we 
may give 3 min. (0.2 c.c.) of Fowler's solution three times a 
day, and increase the dose by a minim (0.06 c.c.) a day until 
physiologic effects are seen. These are puffiness about the 
eyes, nausea, griping pains or diarrhea. In many cases from 
10-15 mm - three times a day can be taken before untoward 
symptoms develop. When these occur the drug should be 
suspended for two or three days and then resumed at a dose 



DISEASES OF THE NERVOUS SYSTEM. 635 

slightly less than the child was receiving when the phenomena 
of salivation appeared. Arsenic should always be given after 
meals, and well diluted. While taking large doses of arsenic 
the patient should be kept under close observation, as albu- 
minuria, conjunctivitis, inflammatory diseases of the skin, or 
even multiple neuritis may develop independently of the usual 
untoward effects. 

In the cases in which arsenic fails or is not well borne, cim- 
icifuga may succeed. A dose of 10 min. (0.6 c.c.) of good 
fluid extract may be given three times after meals and grad- 
ually increased to \ dr. (2.0 c.c.) or more. Antipyrin, in doses 
of from 30-60 gr. (2.0-4.0 gm.) a day, has been strongly ad- 
vocated by Dujarden-Beaumetz, Legroux, Starr, Comby, and 
others, but when used so freely this drug may cause prostra- 
tion, acute anemia, cyanosis, and hemoglobinuria. When 
symptoms of acute rheumatism are present salicylates are of 
service, otherwise they usually fail. When the movements are 
very violent and interfere with sleep, hyoscin hypodermically 
in doses of from yxro^Tiro °^ a & r - (0.0003-0.0006 gm.) twice daily, 
often acts most happily. If hyoscin fails recourse must be had 
to chloral, bromids, or morphin, but these drugs should not 
be used unless the symptoms are of great severity. Chloral- 
amid and trional are reliable hypnotics. 

Iron is often required to combat the marked anemia which 
is present in many cases. 

Chorea Insaniens. — Powerful sedatives like hyoscin, 
chloral, and morphin are required to allay the violent excita- 
bility and jactitation. Inhalations of chloroform are sometimes 
useful. Stimulants are almost always required. When the 
patient is unable to swallow no time should be lost in resorting 
to forced feeding. Severe cases of chorea complicating preg- 
nancy will call for the induction of premature labor. 

EPILEPSY. 

Although in the vast majority of cases epilepsy is an incur- 
able disease, yet much can often be done to lessen the fre- 
quency of the paroxysms. Hygienic treatment is of the 
utmost importance. Moderate exercise, both mental and 
physical, is beneficial. Idleness and seclusion have a baneful 
effect. Children should be kept at school, but competition 
and overstudy should be avoided. Home training must be 
carried on with the greatest care, much tact and firmness being 
required to prevent loss of self-control. Children who are 
particularly irascible are often much better trained in a special 
institution. Adults should follow, if possible, some light and 



636 APPLIED THERAPEUTICS. 

agreeable pursuit, preferably one which will permit them to 
spend the greater part of the day in the open air, and which 
will not add to the risk of physical injury should attacks come 
on without warning. The establishment of so-called epileptic 
colonies or farms, where patients can be employed in agricul- 
tural pursuits, has proved a great boon to many epileptics of 
the bread-winning class. In such institutions as are to be 
found at Biellefeld, Potsdam, and Stettin in Germany, at 
Zurich in Switzerland, at Chalfont St. Peter in England, and at 
Craig Colony in New York, large numbers of sane epileptics 
are able to support themselves under proper care and super- 
vision. 

The diet should be nutritious, but simple and readily diges- 
tible. As a rule a diet that is for the most part vegetable will 
be found to be best adapted to the patient's condition, but when 
the disease is associated with lowered vitality a fair amount of 
animal food should be permitted. Overloading of the stomach 
is a potent factor in precipitating attacks. The principal meal 
is best taken at midday, and full evening meals should be 
avoided. The assertion made by Richet and Toulouse that it 
is advantageous to reduce the sodium chlorid taken with food 
to a minimum — that is, to 2J— 3 gm. a day — has been con- 
firmed by several observers. 

Tea, coffee, alcohol, and tobacco should be used very spar- 
ingly, if at all. The patient must be constantly warned against 
excesses of every kind. The digestive functions should be 
brought to the highest possible state of efficiency. The bowels 
must be regulated by diet, and, if necessary, by mild aperients. 
Liberal water-drinking, frequent bathing, followed by friction 
of the skin, light exercise in the open air, and other measures 
which favor elimination are to be recommended. General ton- 
ics, like iron, arsenic, and cod-liver oil, are sometimes required 
to combat anemia and malnutrition. 

Although very few cases of epilepsy are purely reflex, local 
irritation — phimosis, adherent prepuce, worms, a foreign body 
in the nose or ear, and painful cicatrices — should be carefully 
sought for, and if found removed. Epileptic patients ought 
not to marry. 

Special Treatment. — Among palliative remedies the 
bromids, originally recommended by Locock in 1853, h°ld the 
first place. The ammonium and sodium salts are generally 
preferable to the potassium salt, being less depressing and less 
irritating to the stomach. In cases in which the digestive tract 
is especially sensitive, or in which only a mild effect is desired, 
the strontium salt may be selected with great advantage. A 



DISEASES OF THE NERVOUS SYSTEM. 637 

combination of bromids sometimes acts more satisfactorily 
than a single bromid. N The amount of the drug required 
varies with the severity of the case and the susceptibility of 
the individual, and must be determined experimentally in each 
case. The requisite daily dose usually ranges between 1 and 
2 drams (4.0-8.0 gm.). The addition of one or two drops of 
Fowler's solution to each dose of bromid is useful in pre- 
venting the occurrence of acne. When the attacks occur at 
irregular intervals the bromid is best given in equal doses thrice 
daily after meals. When, however, some periodicity is mani- 
fested it is advisable to administer the drug in relation to the 
time of the attacks. Thus in nocturnal epilepsy a single large 
dose at bedtime may suffice. Again, in women, when the 
seizures occur only at the menstrual periods, active medication 
may be restricted to the week preceding each period. When 
the convulsions occur at long intervals and show no tendency 
to increase in frequency, it is better to dispense with special 
medication entirely and to rely upon hygienic and dietetic 
measures to lessen the excitability of the nerve-centers. In 
every case it is of the utmost importance to limit the dose of 
the bromids to the smallest possible amount that will control 
the seizures. Relief that comes only with saturation is gener- 
ally dearly purchased. 

Mention has already been made of the fact that the with- 
drawal of salt from the diet renders the patient more susceptible 
to the action of the bromids. The theory is that the tissues 
deprived of sodium chlorid more readily take up the bromids 
owing to the lack of other halogen bases in the dietary. Cer- 
tain drugs, not very effective in themselves, are of service when 
combined with the bromids in that they lessen the amount of 
the latter required to control the convulsions. Antipyrin is 
one of the best of these auxiliary remedies. A daily dose of 
10 gr. (0.6 gm.) not infrequently doubles the power of the 
bromids. Such a combination as that mentioned on page 114 
proves valuable in many cases. Antipyrin may also be used 
in those cases in which the bromids, even in small doses, are 
not well borne. Acetanilid in daily doses of from 8-10 gr. 
(0.5-0.6 gm.) is sometimes substituted for antipyrin. In noc- 
turnal epilepsy chloretone (5 gr. — 0.3 gm.) or sulphonal (5-10 
gr. — 0.3-0.6 gm.) is often a useful adjuvant to the bromids. 
On account of its tendency to accumulate in the system and 
cause chronic poisoning, sulphonal should not be used contin- 
uously for longer periods than a week or ten days. Horse 
nettle {solanum carolinense) is another remedy which appears to 
increase the activity of the bromids. From J— 1 fl. dr. (2.0- 



638 APPLIED THERAPEUTICS. 

4.0 c.c.) of the fluid extract may be given thrice daily. When 
the circulation is weak a combination of digitalis or of adonis 
vernalis with the bromids, as recommended by Bechterew, will 
be found efficacious. In petit mat nitroglycerin in doses of 
^ 2^ gr. (0.0006-0.003 gm.) is sometimes of more service 
than the bromids. 

Flechsig's treatment, which consists in giving large doses of 
opium for six weeks and then the bromids for two weeks (see 
p. 97), has been employed with some success in obstinate cases. 
It is not tolerated, however, by many patients and its employ- 
ment necessitates a supervision that can be furnished only in 
fully equipped hospitals. Moreover it is not without danger. 

Surgical Treatment. — Many attempts have been made to 
combat epilepsy by surgical treatment. Recourse has been 
had to castration, circumcision, clitoridectomy, tracheotomy, 
ligation of the carotids, ligation of the vertebral arteries, re- 
moval of the superior cervical sympathetic ganglia, and excision 
of certain cortical areas. Fortunately most of these measures 
are purely of historical interest. Trephining offers some hope of 
relief in certain cases of focal epilepsy, although it has to its credit 
less than 4 per cent, of recoveries. Clark l thus summarizes the 
present status of trephining : I. Idiopathic epileptics with typi- 
cal grand mal seizures should never be trephined. 2. Idio- 
pathic epileptics in whom the seizures are of the Jacksonian 
type should be trephined only when infantile cerebral palsies 
can be excluded, and when the family and personal degeneracy 
is at a minimum. If operation is determined upon in such 
cases a very thorough removal of the epileptogenic area should 
be made ; even then but a fraction of I per cent, recover from 
their epilepsy. Traumatic epileptics may be trephined when 
the injury is definitely proved and stands in direct causal rela- 
tion and has existed not more than two years. The prognosis 
will then largely rest upon the degree of the neurotic predis- 
position present. The earlier trephining is resorted to after 
convulsions begin, the better the prognosis. 

Treatment of the Attack. — When an aura is perceived 
it is often possible to arrest the paroxysm by the inhalation of 
amyl nitrite. Patients may provide themselves with this drug 
in the form of pearls which may be crushed in the handker- 
chief. When the attack is preceded by a local spasm forcible 
extension of the part sometimes succeeds in aborting it. If a 
sensory aura is felt in a limb the part may be firmly grasped 
or encircled with a tight ligature. The patient himself often 
learns by experience some method by which he can suppress 

1 Medical Record, Jan. 12, 1901. 



DISEASES OF THE NERVOUS SYSTEM. 639 

seizures of which there is due warning. During the attack 
there is little to be done beyond protecting the patient from 
injuring himself. The head should be slightly raised, the 
clothes loosened, and a piece of cork or firm rubber pushed 
between the teeth. If necessary inhalations of amyl nitrite or 
chloroform may be used. In the status epilepticus the most 
reliable measures are inhalations of chloroform, ether, or amyl 
nitrite, hypodermic injections of hyoscin (y^- gr. — 0.0006 gm.) 
or of morphin (J gr. — 0.016 gm.), enemas of chloral (20-30 
gr. — 1.3-2.0 gm.), and the hot bath. 



NEURASTHENIA. 

The treatment of neurasthenia must vary with the cause of 
the disease and the circumstances and idiosyncrasies of the 
patient. In every case an earnest effort should be made to 
determine the exciting cause and to remove it if possible. With 
this in mind the family history of the patient, his occupation, 
habits, and amusements, and the condition of his various 
organs must be carefully studied. 

In the milder forms of the disease, especially when overwork 
has been the exciting factor, a month or two of rest with 
change of scene will often effect a cure. In such cases quiet 
travel, so planned that it will interest the patient without 
fatiguing him, is frequently attended with excellent results. A 
prolonged sea-voyage is sometimes very useful. In other cases 
the " wilderness cure " of S. Weir Mitchell may be recom- 
mended with advantage. 

In the absence of any special gastric disturbance, the diet 
should be simple, readily digestible, and abundant. Tea, cof- 
fee, alcohol, and tobacco are better avoided. A tepid sponge 
bath in the morning, provided it be followed by a good 
reaction, is beneficial. The wet pack, sitz-bath, spinal douche, 
and Scottish douche are of service in individual cases. 

The question of exercise is an important one. When the 
physical strength is fairly well maintained exercise in the open 
air, systematically carried out and cautiously increased, often 
yields admirable results, but the fact cannot be too strongly 
emphasized that any exertion pushed to the point of fatigue is 
distinctly harmful. In many cases it is advisable to substitute 
for active exercise passive movements and massage. 

When there is marked muscular weakness as well as ner- 
vous inefficiency rest is imperative. This may be relative or 
absolute. In some cases the addition of from three to five 
hours to the time usually spent in bed, or a rest in bed of a 



64O APPLIED THERAPEUTICS. 

few hours during the day, will suffice. When, however, the 
symptoms are severe it will be necessary for the patient to give 
up all work for a period of from six to twelve weeks. In such 
cases much good accrues from the " rest cure " introduced by 
S. Weir Mitchell. This treatment includes not only rest but 
also full feeding, isolation, and artificial exercise. Of course, the 
details of the treatment must vary in each case, and only the 
outlines can be given here. 

Rest. — In bad cases, for the first two or three weeks at least, 
rest must be absolute, the patient not being allowed to feed 
himself nor to leave the bed to pass urine or to empty the 
bowels. As to this point Mitchell says : " In some instances 
I have not permitted the patient to turn over in bed without 
aid, and this I have done because sometimes I think no 
motion desirable and because sometimes the moral influ- 
ence of repose is of use." As improvement becomes manifest 
by a gain in weight, in muscular strength, and in nervous 
energy, some relaxation is permissible, and the patient may be 
allowed to sit up in bed to take meals and to indulge for a short 
time each day in reading or simple games. After four or five 
weeks he may be permitted to sit up in a chair for five or ten 
minutes a day, the time being gradually lengthened until at 
the end of a week or ten days he is up for from four to five 
hours. Active exercise is now cautiously introduced, and soon 
he is allowed to go out for a short walk or a drive. Finally, 
it is desirable that he should spend a week or two at the sea- 
shore or in the country before returning to his home. 

Feeding. — In most cases the diet at first should be restricted to 
milk. From 4-5 oz. ( 1 20.0- 1500 c.c.) should be given every two 
hours, and this amount gradually increased until at the end of 
a week or ten days from 8-10 oz. (235.0-300.0 c.c.) are given 
every two hours. Little by little solid food may now be added 
until at the end of two or three weeks the patient is getting 
each day three full meals with from 3-4 pints (1.5-2.0 L.) of milk 
in the intervals. The solid food may include stale bread with 
butter, soft-boiled or poached eggs, thoroughly cooked cereals, 
oysters, sweet breads, broiled or roasted meats, green vegetables, 
cooked fruits, milk-puddings, and ice cream. The evening 
meal should be light. 

Isolation. — This is an essential element in the treatment. No 
one should be permitted to see the patient except the medical 
attendant and the nurse. Even the writing and receiving of 
letters are to be forbidden. 

The permanent return of the patient at the close of the 
treatment to his family and friends should be effected very 



DISEASES OF THE NERVOUS SYSTEM. 64 1 

gradually. Any infringement of these rules is almost sure to 
mar the success of the treatment 

Artificial Exercise. — This is supplied in the form of massage 
and electricity. Through these measures the good effects of 
active exercise can be secured in a measure without the expen- 
diture of any energy on the part of the patient. Massage 
should not be practised until the second or third day of the 
treatment, and even then it should be introduced very grad- 
ually. At first the seances should not last longer than a few 
minutes, but ultimately they may be increased to an hour a 
day. It is very important, as Dercum has urged, that the mas- 
sage be performed by the nurse instead of another person with 
whom the patient would have to become acquainted. 

Electricity, according to Mitchell, is the least necessary part 
of the treatment. It is, however, a useful adjuvant. Like the 
massage it should be introduced very gradually, otherwise it is 
likely to excite the patient and so prove harmful. A slowly 
interrupted faradic current is generally preferred. This should 
be applied once a day to each group of muscles in such 
strength as to elicit slight contractions. 

Success in the rest treatment will depend quite as much 
upon the way in which the various measures are applied as upon 
the measures themselves. The fact must not be lost sight of 
that suggestion and discipline play a conspicuous part in the 
treatment ; hence the importance of having all the details sys- 
tematically and strictly carried out. It is always advisable to 
furnish a program indicating exactly what shall be done at 
each hour of the day. It is absolutely necessary that the 
nurse chosen to conduct the treatment shall be not only skil- 
ful and robust but also discrete, tactful, and agreeable to the 
patient. Finally, the more thoroughly the physician is able to 
inspire confidence in the patient and to convince him that his 
disease is not an incurable one, the more likely is he to effect 
a cure. 

Medicinal Treatment. — Drugs are of little value except 
in meeting underlying conditions and in combating special 
symptoms. When there is anemia, iron and arsenic will be 
found useful. Small doses of strychnin are sometimes bene- 
ficial, but more often the drug is useless or actually harmful. 
Indigestion may be sufficiently severe to demand a modifica- 
tion of the dietetic treatment and the use of special remedies 
(see p. 555)- Such drugs as asafetida, valerian, and sumbul 
are often helpful in allaying nervous irritability. The follow- 
ing pill, introduced by Goodell, may often be given with ad- 
vantage : 

41 



642 APPLIED THERAPEUTICS. 

ft Arseni trioxidi, gr. ss (0.03 gm.) ; 

Ferri sulphatis exsiccati, 

Extracti sumbul, aa gr. xx (1.3 gm.) ; 

Asafoetidae, gr. xl (2.6 gm.). — M. 

Fiant pilulse, No. xx. 
Sig. — One three or four times a day. 

Every effort should be made to secure sleep by general 
measures — tepid baths, wet-packs, and gentle massage — before 
resorting to drugs. If a somnifacient becomes absolutely 
necessary, sodium or ammonium bromid, chloralamid, or tri- 
onal may be given. Chloral and morphin should be withheld 
on account of the grave danger of inducing a drug habit. 
Severe headache may call for an occasional dose of phenacetin 
or of a bromid. Constipation can usually be controlled by 
diet and abdominal massage, but in some cases mild laxatives, 
like cascara sagrada, sodium phosphate, or the combination of 
aloin, belladonna, and strychnin will be required. 

HYSTERIA. 

By proper mental, moral, and physical training much can be 
done to prevent the occurrence of hysteria in those who 
through inheritance are predisposed to the disease. Prophy- 
lactic treatment includes the inculcation of absolute obedience, 
self-restraint, and self-denial, a judicious education, suitable 
outdoor exercise, hygienic surroundings, temperate living, and 
the avoidance of all that tends to morbid emotionalism or sen- 
timentalism. 

In developed hysteria treatment must be directed both to the 
mind and the body, but especially to the former. To be suc- 
cessful the physician must be able to inspire absolute confidence 
and faith in the mind of the patient. She must be impressed 
repeatedly with the fact that her condition is a curable one, 
and that with her thorough co-operation restoration to health 
will certainly follow. To intimate that her symptoms are 
feigned or are wholly within her control is an egregious error. 
The physician's authority must be unquestioned and his in- 
structions must be rigidly carried out. Want of firmness and 
of decision is a common cause of failure. Harsh measures are 
occasionally needed, but they should be adopted only after the 
most careful consideration. In many cases no method of 
treatment proves successful until the patient has been removed 
from her customary surroundings and separated from her sym- 
pathetic relatives and friends. 

Suggestion is employed consciously or unconsciously in the 
treatment of hysteria by every successful physician. Without 



DISEASES OF THE NERVOUS SYSTEM. 643 

it many of the remedies recognized as efficacious become 
wholly impotent. The cures which have been ascribed to the 
application of magnets and of various metals (metallotherapy) 
to the surface of the body seem to have been solely the result 
of suggestion. Complete hypnotism is by no means so gen- 
erally useful as continuous suggestion. Certain symptoms — 
paralysis, aphonia, blindness, contracture, and anesthesia — are 
sometimes removed by a single hypnotic seance, but on the 
whole the action of hypnotism is disappointing. Moreover, in 
the event of failure it seems capable of still further lowering 
the will-power and of increasing the emotional excitability. 

The physical condition of the patient must not be neglected. 
The general measures referred to under neurasthenia (see p. 
639), such as hydrotherapy, systematic exercise in the open 
air, massage, and electricity, are equally applicable here. In 
grave cases of hysteria the treatment associated with the name 
of S. Weir Mitchell (see p. 640) often yields admirable results, 
but it is not suitable in every case, and considerable judgment 
must be exercised in the selection of proper subjects for it. 
Concerning this point Playfair writes : " The worse the case is 
the more easy and certain is the cure ; and the only disappoint- 
ments I have had have been in dubious, half-and-half cases." 

Apart from their moral effect, drugs have but little influence 
upon hysteria. They must often be used, however, to meet 
underlying conditions and to combat special symptoms. Iron 
and arsenic are useful when there is anemia. Antispasmodics, 
like valerian, sumbul, asafetida, and camphor, are serviceable in 
allaying abnormal nervous irritability. Occasionally more 
powerful sedatives, like the bromids, phenacetin, and chloral- 
amid, may be demanded, but the continuous use of such rem- 
edies is always to be condemned. Such drugs as morphin, 
alcohol, and chloral are distinctly dangerous. 

When hysteria is complicated by local disease special treat- 
ment will be required, but no operation should ever be per- 
formed for the relief of nervous symptoms unless there exists 
an actual organic lesion. 

Treatment of Special Symptoms. — Convulsions. — Iso- 
lation of the patient is imperative. Firm pressure over the 
ovarian region is often successful. The affusion of cold water 
over the face is useful. Inhalations of amyl nitrite, or even of 
chloroform, may be employed if necessary. Strong faradic 
currents applied to the spine are occasionally efficacious. An- 
esthesia is best treated by electricity, especially by the faradic 
wire-brush. Static electricity, owing to the profound mental 
impression which it produces, is also useful. Hyperesthesia 



644 APPLIED THERAPEUTICS. 

and pain often yield to the continuous or interrupted galvanic 
current. In paralysis the patient should be instructed how to 
regain by long-continued practise the use of the affected part. 
This process of re-education demands the exercise of great 
firmness and patience. Swedish movements, massage, and 
faradization are useful adjuvants. In aphonia the faradic cur- 
rent, applied by means of special electrodes, is the most re- 
liable remedy. In contractures the most useful measures are 
massage, passive movements, and faradization. In obstinate 
cases it may be advisable to straighten the affected joint under 
an anesthetic and then apply a splint to the limb. 



WEIGHTS AND MEASURES, 



APOTHECARIES' WEIGHT. 

Troy grains. Scruples. Drams. Troy ounces. Pound, 
gr. 20 = 9 I 

60 = 3 = 31 

480 24 8 = I 1 

5760 = 288 = 96 = 12 = ft> 1 



APOTHECARIES' (WINE) MEASURE. 

Minims. Fluidrams. Fluidounces. Pints. Gallon. 

Tt\, 60 = f£ I 

480 = 8 = fg I 

7680 = 128 = 16 = Ol 

61440 = 1024 = 128 = 8 = C. 1 



APPROXIMATE FLUID MEASURES. 

Teaspoonful = f^j. Tablespoonful = f^iv. 

Dessertspoonful = fgij. Wineglassful = f|ij. 

Teacupful = f^iv. 

A drop is usually considered equivalent to a minim, but this is the 
case only with a drop of water under certain conditions. The size of 
the drop varies with the shape of the vessel from which the liquid is 
being dropped and with the character of the liquid. The broader and 
thicker the lip of the bottle the larger is the size of the drops. Again, the 
lighter the liquid and the greater its viscidity the larger is the size of 
the drops. Chloroform and bromin, being very heavy, each drop 
about 250 drops to the fluidram ; tinctures, spirits, and fluid extracts 
drop from 130 to 150 drops to the fluidram ; oils, except castor oil, from 
105 to 140 drops to the fluidram ; syrup, from 45 to no drops to the 
fluidram ; and waters and solutions, from 60 to 90 drops to the fluidram. 



WEIGHTS AND MEASURES. 



645 



I myriagram (Mg.) 
I kilogram (Kg.) 
I hectogram (Hg.) 
I decagram (Dg.) 
I gram (Gm.) 
I decigram (dg.) 
I centigram (Cg.) 
I milligram (mg.) 



METRIC WEIGHTS. 



10,000 grams. 

1000 grams. 

100 grams. 

10 grams. 

weight of 1 cubic centimeter of water at 4 C. 

tenth part of I gram, or 0.1 gram. 

hundredth part of I gram, or 0.01 gram. 

thousandth part of I gram, or 0.00 1 gram. 



METRIC MEASURES OF CAPACITY. 



I myrialiter (Ml. i) = \ 

I kiloliter (Kl. 1) = j 

1 hectoliter (HI. 1) = j 

1 decaliter (Dl. 1) = / 

I liter (L.) = j 

I deciliter (dl. or L. .1) = -/ 

I centiliter (cl. or L. 01) = \ 

I milliliter (ml. or j 

L. 001) ~ \ 



10 cubic meters, or the measure of 10 milli- 
liters of water. 

1 cubic meter, or the measure of 1 milliliter 
of water. 

100 cubic decimeters, or the measure of 1 
quintal of water. 

10 cubic decimeters, or the measure of I myria- 
gram of water. 

I cubic decimeter, or the measure of I kilo- 
gram of water. 

1 00 cubic centimeters, or the measure of 1 
hectogram of water. 

10 cubic centimeters, or the measure of I deca- 
gram of water. 

I cubic centimeter (c.c), or the measure of I 
gram of water. 



RULES FOR CONVERTING DRAMS AND GRAINS INTO THEIR 
METRIC EQUIVALENTS. 

To convert drams into grams, multiply the number of drams by 
3.9 grams, which is the number of grams in 1 dram. To convert 
grains into the corresponding metric quantity, multiply the number of 
grains by .065, which is the metric equivalent of 1 grain. 

RULES FOR CONVERTING METRIC QUANTITIES INTO DRAMS 
AND GRAINS. 

To convert grams into drams, divide the number of grams by 3.9. 
To convert grams into grains, divide the number of grams by .065. 



EQUIVALENTS OF APOTHECARIES' IN METRIC WEIGHTS. 

Grain. Gram. Grain. Gram. 

.0324 

= .0648 

= .1296 

.3240 

.5184 

= .6480 

= .9720 

= I.2960 

= I.944O 

= 2.5920 

3.888 



-5-5-0 

i 

1 
I 



Gram. 


Grain 


.OOO324 


l 


.OOO43 


I 


.OO064 


2 


.OO086 


5 


.OOI29 


8 


.OOI62 


10 


.OO324 


15 


.00648 


20 


.OI08 


30 


.Ol62 


40 


.02l6 


60 



646 



APPLIED THERAPEUTICS. 



EQUIVALENTS OF APOTHECARIES' IN METRIC MEASURES. 



!inims. 




Cubic centimeters. 


Fluidounces. 




Cubic centimeters 


I 


= 


O.061 


I 


= 


29.57 


2 


= 


O.I23 


2 


= 


5914 


3 


= 


O.185 


3 


= 


89.OO 


5 


= 


O.308 


4 


= 


II8.29 


7 


= 


O.43I 


6 


= 


17742 


10 


= 


O.616 


10 


= 


295-73 


15 


= 


O.924 


12 


= 


355-0O 


20 


= 


I.23 


16 


= 


473-17 


30 


= 


I.84 


20 


= 


59i-5o 


40 


= 


2.46 


24 


= 


71000 


60 


= 


3-7 


32 


- 


946.35 



PERCENTAGE IN SOLUTIONS. 

To estimate the quantity of a drug required to make a fluidounce or 
pint of a solution of a given percentage, multiply the weight of a fluid- 
ounce or a pint of the liquid to be used as the solvent by the percentage. 
Thus, in an ounce of a 10 per cent, aqueous solution of silver nitrate 
there are 45.5 grains, 

455.7 grains (weight of a fluidounce of water) x o. I (percentage) = 45.5 grains. 

In a pint of the same solution there are 729. 1 grains. 

7291 grains (weight of a pint of water) x 0.1 (percentage) = 729 I. 

If a pint of a 1 : 1000, 1 : 100, or 1 : 40 solution be required, divide 
7291 by 1000, 100, or 40, as the case may be, to determine the quan- 
tity of the drug. Thus, in a pint of corrosive sublimate solution 
(1 : 1000) there are 7.29 grains of the drug. 

7291 grains h- 1000 = 7.29 grains. 

To determine the weight of a fluidounce or pint of a liquid other than 
water, multiply 455.7 or 7291 by the specific gravity of the liquid, and 
the product will be the weight desired. 



INDEX 



[To obviate the inconveniences attending the use of two separate indexes — an Index of 
Diseases and an Index of Remedies — the author has employed but one general index. The 
name of each disease is printed in bold-faced type, and under it are grouped the remedies 
employed in the disease.] 



Abortion, threatened 

opium, 96 

viburnum prunifolium, 140 
Abrin, 447 
Abrus, 447 
Abscesses 

carbolic acid, 389 
formalin, 404 
hydrogen dioxid, 408 
iodoform, 320 
Acacia, 460 
Aceta, 19 
Acetanilidum, 347 

Acetonemia. See also Diabetes mel- 
litus. 
hypodermoclysis, 496 
infusion, 496 
sodium bicarbonate, 172 
Acetphenetidinum, 351 
Acetum, 451 
Acetylsalicylic acid, 400 
Acid, acetic, 451 
agaric, 264 
arsenous, as an antimalarial, 414; as 

a poison, 307 
benzoic, 401 
boracic, 411 
boric, 411 
camphoric, 264 
carbazotic, 394 

carbolic, 387; as a poison, 368 
cathartinic, 206, 207 
chromic, 451 
cinnamic, 190, 278 
citric, 469 
gallic, 357 
hydriodic, 317 
hydrobromic, 116 
hydrochloric, 181 
hydrocyanic, 160 
lactic, 452 



Acid, nitric, 449 

nitrohydrochloric, 449 

osmic, 453 

oxalic, 249 

phosphoric, 301 

picric, 394 

prussic, 160 

pyrogaiiic, 453 

quinic, 244 

salicylic, 395 

sozoidolic, 390 

sulphuric, 448 

sulphurous, 407 

tannic, 354 

thymic, 392 

trichloracetic, 451 
Acidum aceticum, 451 

arsenosum as a poison, 307; as an 
antimalarial, 414 

benzoicum, 401 

boricum, 411 

camphoricum, 264 

citricum, 469 

gallicum, 357 

hydriodicum, 317 

hydrobromicum dilutum, 116 

hydrochloricum, 181 

hydrocyanicum, 160; as an anti- 
emetic, 170; as a poison, 160 

lacticum, 452 

nitricum, 449 

nitrohydrochloricum, 449 

osmicum, 453 

oxalicum, 249 

phosphoricum, 300 

picricum, 394 

salicylicum, 395 

sulphuricum, 448; as an antihydrotic, 
264; as a poison, 449 

sulphurosum, 407 

tannicum, 354 

647 



648 



INDEX. 



Acidum trichloraceticum, 451 
Acne 

ichthyol, 335 

Rontgen rays, 505 

sulphur, 201 

sulphurated lime, 340 
Aconite, 60; as an antipyretic, 352; as 
a local anesthetic, 159; as a poison, 
62 
Aconitin, 60 
Acromegaly 

pituitary body, 345 
Actinomycosis 

potassium iodid, 315 
Actinotherapy, 504 
Action, cumulative, of drugs, 37 
Actol, 373 
Acupuncture, 438 
Addison's disease 

suprarenal gland, 68 
Adenitis 

arsenic iodid, 311 

blue ointment, 327 

Crede's ointment, 374 

Donovan's solution, 331 

ferrous iodid, 295 

ichthyol, 335 

iodin, 318 

lead iodid, 317 

mercuric iodid, 331 
oxid, 333 
Adeps lanae, 464 

hydrosus, 464 
Adonidin, 56 
Adonis vernalis, 56 

Adrenalin, 66; as a circulatory stimu- 
lant, 59; as a hemostatic, 378 
^Ether, 118; as a local anesthetic, 161; 
as a circulatory stimulant, 123; as a 
spinal cord depressant, 150 
^Ethylis bromidum, 128 
carbamas, no 
chloridum, 129 
Agaricin, 264 
Agurin, 223 

Alcohol, 43; as a poison, 45; as a sto- 
machic, 179 
Alcoholism 

treatment, 46 
Ale, 44 

Alexin of Buchner, 430 
Alkaloids, definition of, 18 
Allium, 282 
Allspice, 191 
Almonds, bitter, 462 

sweet, 462 
Aloe, 204 
Aloin, 204 
Alopecia. See also Seborrhea. 



Alopecia 

actinotherapy {Alopecia areata) , 

S°4 
cantharides, 441 
capsicum, 186 
pilocarpin, 261 
Alteratives, 305 
Althaea, 461 
Alum, 361; as an emetic, 168 

ammonioferric, 295 
Alumen, 361; as an emetic, 168 
Amaurosis 

strychnin, 144 
Amboceptor, 430 
Amenorrhea 
aloes, 204 
apiol, 248 
cimicifuga, 138 
Dewees' mixture, 249 
Dover's powder, 271 
hot foot-bath, 495 
iron, 247 
oxalic acid, 249 
pennyroyal, 256 
potassium permanganate, 248 
senecio, 249 
treatment, 247 
Ammonia, 41 
Ammoniacum, 280 
Ammonii acetas, 262 
bromidum, 115 

carbonas, 276; as a circulatory stimu- 
lant, 43 
chloridi, 275 
iodidum, 316 
salicylas, 399 
valeras, 135 
Ammonium valerate, 135 
Amygdala, 462 
Amyl nitrite, 69 
Amylis nitris, 69 
Amylum, 463 
Analgesics, 130 
Anaphrodisiacs, 244 
Anemia 

arsenic, 310 
cod-liver oil, 304 
iron, 290 
massage, 486 
mercuric chlorid, 486 
treatment, 547 
Anemia, pernicious 

treatment, 547 
Anemia, splenic 
treatment, 548 
Anemonin, 65 
Aneson, 106 

Anesthesia, infiltration, 86 
Anesthesin, 156 



INDEX. 



649 



Anesthetics, general, 118 

local, 153 
Aneurysm, aortic 

bleeding, 503 

calcium cnlorid, 383 

gelatin, 382 

electricity, 483 

ice-bag, 492 

Moore-Corradi treatment, 483 

potassium iodid, 315 

veratrum, 64 
Angina pectoris 

amyl nitrite, 70 

arsenic, 310 

atropin, 80 

chloroform, 127 

digitalis, 51 

erythrol tetranitrate, 72 

Hoffmann's anodyne, 136 

nitroglycerin, 71 

opium, 96 

potassium iodid, 315 
treatment, 615 
Anisum, 191 
Anodynes, 130 
Antacids, gastric, 170 
Anthelmintics, 422 
Anthemis, 176 
Anthracene derivatives, 198 
Anthrax 

carbolic acid, 389 
Antianthrax serum, 436 
Anticonvulsants, 130 
Antidysenteric serum, 437 
Anti-emetics, 168 
Antifebrin, 348 
Antihydrotics, 262 
Antimalarials, 414 
Antimeningococcic serum, 434 
Antimonii et potassii tartras, 271; as an 

emetic, 167; as a poison, 272 
Antimonium, 271 
Antimony, 271 

and potassium tartrate, 271. See 

Tartar emetic. 
Antinosin, 322, 391 
Antipneumococcic serum, 434 
Antipyretics, 346 
Antipyrin, 350 
Antisepsis, gastro-intestinal, 386 

surgical, 385 
Antiseptics, 383 

urinary, 386 
Antispasmodics, 131 
Antistreptococcus serum, 433 
Antitoxin diphtheria, 431 

tetanus, 432 
Antitoxins, 428 
Antituberculous serum, 435 



Antityphoid serum, 437 
Antivenene, 437 
Anus, fissure of 
Anesthesin, 156 

belladonna, 79 

iodoform, 320 

orthoform, 155 

silver nitrate, 371 
Aphrodisiacs, 244 
Apiol, 248 

Apocodein hydrochlorid, 274 
Apocynum, 225 
Apolysin, 352 
Apomorphinas hydrochloridum, 273; as 

an emetic, 166 
Apoplexy 

bloodletting, 503 

croton oil, 211 

electricity, 481 

ice-cap, 492 

massage, 485 

strychnin, 144 
treatment, 624 
Appendicitis 

treatment, 571 
Aqua hydrogenii dioxidi, 408 
Aquae, 19 
Arbutin, 240 

Arecolin hydrobromid, 165 
Argentamin, 373 
Argenti nitras, 370 

oxidum, 370 
Argentum, 369 

colloidale, 374 
Argyrol, 373 
Arhythmia 

digitalis, 52 
Aristol, 321, 392 
Arnica, 444 
Arseni bromidi, 312 
iodidum, 312 
trioxidum, 305 
Arsenic, 305 

trioxid, 305, 456 
Arsenic-poisoning 

dialyzed iron, 293 

ferric hydrate, 293 
treatment, 308 
Arsenum, 305 
Arteriosclerosis 

erythrol tetranitrate, 72 

nitroglycerin, 71 

potassium iodid, 314 
Arthritis 

blisters, 441 

blue ointment, 327 

Crede's ointment, 374 

dry heat, 495 

ichthyol, 335 



650 



INDEX. 



Arthritis 

iodin, 318 

iodoform, 320 

massage, 486 
Asafetida, 134 
Aspidium, 423 
Aspidosperma, 274 
Aspirin, 400 
Asthma 

amyl nitrite, 70 

arsenic, 310 

belladonna, 78 

bromids, 113 

cannabis indica, 101 

chloralamid, 106 

chloroform, 126 

conium, 151 

cubeb, 288 

gelsemium, 149 

grindelia, 283 

heat, 495 

heroin, 99 

Hoffmann's anodyne, 136 

lobelia, 152 

opium, 96 

paraldehyd, no 

potassium iodid, 315 
nitrate, 229 

quebracho, 274 

stramonium, 81 
treatment, 587 
Astringents, 353 
Atoxyl, 312 
Atropin, 75; as an antihydrotic, 263; as 

a mydriatic, 161 
Aurantium, 470 
Auri et sodii chloridum, 336 



Bacteriolysins, 429 
Bacteriolysis, 430 
Balsam dipterocarpus, 446 

of copaiba, 234 

of Peru, 279 

of Tolu, 279 
Balsams, definition of, 18 
Balsamum Peruvianum, 279 

Tolutanum, 279 
Barii sulphidum, 456 
Basham's mixture, 292 
Bath, cold, 491 

hot-air, 494 

hot-vapor, 494 

hot-water, 494 

Russian, 495 

Turkish, 494 
Bearberry, 240 
Bed-sores. See also Ulcers. 
balsam of Peru, 279 



Bed-sores 

glycerin, 467 

lead plaster, 365 
treatment, 513 
Beer, 44 
Belladonna, 75; as an antihydrotic, 263; 

as a mydriatic, 162; as a poison, 77 
Benzaldehydum, 463 
Benzoinum, 277 
Benzonaphthol, 395 
Benzosol, 287 
Benzosulphinidum, 473 
Berberin, 379 
Betanaphthol, 394 
Betanaphthol-bismuth, 395 
Betol, 401 

Bismuth subsalicylate, 376, 399 
Bismuthi subcarbonas, 376 
subgallas, 376 
subnitras, 374 
subsalicylas, 376, 399 
Bismuthum, 374 
Bites, insect 

ammonia, 42 

witch-hazel, 360 
Bites, snake- 
alcohol, 47 

antivenene, 437 
Black haw, 140 

wash, 331 
Blastomycosis 

Rontgen rays, 505 
Blaud's pills, 292 
Blepharitis 

mercuric oxid ointment, 333 
Blisters, 438 
Blood-letting, 501 
Blood-root, 282 
Blue mass, 210, 326 

ointment, 327 
Boils 

sulphurated lime, 340 
Boneset, 177 
Borax, 412 
Brain, congestion of 

aconite, 62 

elaterium, 215 

hot foot-bath, 495 

ice-cap, 492 

mustard, 443 

potassium bromid, 114 
Brand treatment of typhoid fever, 492 
Brandy, 43 
Brayera, 424 

Bright's disease. See Nephritis. 
Bromidrosis. See also Hyperidrosis. 

chromic acid, 452 

formaldehyd, 404 

potassium permanganate, 409 



INDEX. 



6 5 I 



Bromin, 454 
Bromipin, 454 
Bromism, in 

Bromoform, 116 
Bromoformum, 116 
Bromum, 454 
Bronchitis, acute 

aconite, 62 

ammonium carbonate, 276 
chlorid, 275 

apomorphin, 274 

benzoin, 278 

codein, 99 

conium, 151 

grindelia, 283 

heroin, 99 

hyoscyamus, 81 

iodin (locally), 318 

ipecac, 270 

lactucarium, 138 

lobelia, 152 

mustard (locally), 443 

opium, 96 

potassium citrate, 275 

quebracho, 274 

squill, 288 

stupe of oil of turpentine, 446 

tartar emetic, 272 
treatment, 584 
Bronchitis, chronic 

ammonium chlorid, 275 

apomorphin, 274 

arsenic iodid, 311 

benzoin, 277 

cannabis indica, 101 

cod-liver oil, 304 

copaiba, 234 

creosote, 284 

guaiacol carbonate, 287 

ipecac, 270 

oil of eucalyptus, 281 
of myrtle, 282 
of santal, 288 

opium, 96 

physostigma, 148 

potassium iodid, 315 

senega, 282 

strychnin, 143 

tar, 288 

terebene, 289 

terpin hydrate, 289 
treatment, 585 
Bronchopneumonia. See Pneumo- 
nia, catarrhal. 
Broom, 225 
Brown mixture, 462 
Brucin, 141 

Bruises. See Contusions. 
Bryonia, 215 



Bubo 

iodin, 318 

mercurial ointment, 327 
Bubonic plague 

antitoxin, 436 

vaccines, 436 
Buchner's alexin, 430 
Buchu, 239 
Buckthorn, 199 
Burns 

anesthesin, 157 

bismuth subgallate, 376 

boric acid, 412 

carbolic acid, 390 

carron oil, 173 

chloretone, 106 

continuous warm bath, 495 

hypodermoclysis, 496 

ointment of zinc oxid, 368 

orthoform, 156 

picric acid, 396 

sodium bicarbonate, 172 
Bursitis 

blue ointment, 327 

iodin, 318 
Butternut, 202 
Butyl-chloral hydras, 104 



Cachets, 27 

Cacodylate of sodium, 312 

Cactus grandiflorus, 58 

Cade, oil of, 445 

Caffein, 54; as a diuretic, 222 

Calabar bean, 146 

Calamin, 369 

Calcii carbonas, 377; as an antacid, 173 

chloridum, 383 

glycerophosphas, 302 

bypophosphis, 302 

lactas, 383 

lactophosphas, 302 

phosphas, 301 

sulphidum hydratum, 456 
Calcium chlorid, 383 

lactate, 383 

sulphid, 340, 456 
Calculus, biliary. See Cholelithiasis. 
Calculus, renal. See Nephrolithiasis. 
Calomel, 330; as a cathartic, 209; as a 

diuretic, 232 
Calumba, 175 
Calx, 410 

chlorinata, 406 

sulphurata, 340 
Cambogia, 212 

Camphor, 132; as a circulatory stimu- 
lant, 58 
Camphora, 132 



652 



INDEX. 



Camphora monobromata, 133; as an 
anaphrodisiac, 246 

Cannabis indica, 100 

Cantharis, 440; as an emmenagogue, 
249; as a stimulant to genito- 
urinary tract, 241 

Capsicum, 185 

Capsules, 27 

Caraway, 192 

Carbo, 413 

Carbolic acid, 387 

Carbolic-acid poisoning 
alcohol, 47 

magnesium sulphate, 217 
treatment, 389 

Carbuncle 

carbolic acid, 389 

Carcinoma 

Rontgen rays, 505, 506 

Cardamomum, 188 

Carminatives, 184 

Caroid, 184 

Carron oil, 172 

Carum, 192 

Caryophyllus, 188 

Cascara sagrada, 198 

Cascarilla, 178 

Cassia fistula, 201 

Castor oil, 208 

Cataplasmata, 30 

Cathartics, 193 

Cathartin, 198, 206, 207 

Cathartinic acid, 207 

Caustic potash, 454 
soda, 455 

Caustics, 447 

Cautery, actual, 438 

Cephaelin, 269, 271 

Cerata, 29 

Cerates, 29 

Cerebral depressants, 89 
excitants, 74 

Cerebral hemorrhage. See Apo- 
plexy. 

Cerebrospinal fever 
treatment, 515 

Cerii oxalas, 170 

Cetaceum, 464 

Charing. See Erythema intertrigo. 

Chalk, 377 

Chamomile, 176 

Charcoal, 413 

Charts, 30 

Chartulae, 27 

Chaulmoogra oil, 445 

Chenopodium, 426 

Chilblains 

aconite, 159 
ammonia liniment, 42 



Chilblains 

calcium chlorid, 383 

creosote, 285 

ice, 492 

ichthyol, 335 

iodin, 319 

turpentine liniment, 237 
Chimaphila, 241 
Chirata, 176 
Chiretta, 176 
Chloasma 

lactic acid, 453 
Chloral, 10 1 

camphorated, 103 
Chloralamid, 104 
Chloralformamid, 104 
Chloralose, 105 
Chloralum hydratum, 10 1 

as a poison, 102 
Chloretone, 106; as a local anesthetic, 

157 

Chlorin, 406 
Chlorinated lime, 406 
Chloroformum, 123; as an anthelmin- 
tic, 427; as a rubefacient, 446; as a 
spinal cord depressant, 150 
Chlorosis 

treatment, 547 
Chlorum, 406 
Cholagogues, 193 
Cholelithiasis 

treatment, 573 
Cholera 

atropin, 78 

camphor, 133 

enteroclysis, 498 

heat, 495 

hypodermoclysis, 496 

tannic acid, 356 

vaccine, 436 
treatment, 531 
Cholera infantum 

treatment, 566 
Chordee. See also Gonorrhea. 

camphor, 132 

hops, 139 

monobromated camphor, 134 

opium, 96 

potassium bromid, 114 
Chorea 

acetanilid, 349 

antipyrin, 350 

arsenic, 310 

chloral, 103 

chloroform, 126 

cimicifuga, 138 

gelsemium, 149 

hyoscin, 83, 118 

hyoscyamin, 82 



INDEX. 



653 



Chorea 

opium, 96 

potassium bromid, 113 

salicylic acid, 397 

wet-pack, 493 
treatment, 634 
Chromii trioxidum, 451 
Chrysarobinum, 444 
Chrysophanic acid, 198, 206 
Cimicifuga, 137 
Cinchona, 415 
Cinchonidin, 420 
Cinchonin, 420 
Cinchonism, 416 
Cinnaldehydum, 190 
Cinnamic aldehyd, 190 
Cinnamomum, 190 
Circulatory depressants, 59 

stimulants, 39, 40; acceleration of 

heart-beat from, 40; increase of 

blood-pressure from, 39 
Citrine ointment, 332 
Citrophen, 352 
Clemen's solution, 312 
Cloves, 188 
Clysters, 26 
Coca, 83 

Cocain, 83; as a local anesthetic, 153; 
as a mydriatic, 163; as a poison, 85; 
as a respiratory stimulant, 73 
Cocaina, 83 
Cocainism, 85 
Cocainization, medullary, 87 
Cocculus indicus, 265 
Codeina, 99 
Cod-liver oil, 303 
Coffee, 54 
Colchicina, 336 
Colchicum, 336 
Cold, 491 

cream, 463 
Colic 

asafetida, 134 

atropin, 78 

camphor (intestinal), 132 

chloroform, 126 

hot bath, 495 

morphin, 96 

oil of cloves (intestinal), 189 

peppermint (intestinal), 187 
Collapse 

adrenalin, 68 

ammonia, 42 

atropin, 78 

camphor, 132 

digitalis, 50 

enteroclysis, 499 

ether, 57, 123 

hot bath, 495 



Collapse 

infusion, 496 

strychnin, 143 
Collargol, 374 
Collodia, 25 
Collodion, 468 
Collodions, 25 
Collodium, 468 
Colloidal silver, 374 
Colocynthis, 212 
Columbo, 175 
Comedo 

sulphur, 201 
Complement, 430 
Complementophilic group, 430 
Compound cathartic pills, 212 
Condurango, 176 
Confections, 27 
Conium, 151 
Conjunctivitis 

boric acid, 412 

calomel (phlyctenular), 330 

copper sulphate (granular), 367 

jequirity (granular), 447 

mercuric oxid (phlyctenular), 333 

organic silver salts (purulent), 373 

silver nitrate (purulent), 371 

zinc sulphate, 269 
Constipation 

abdominal massage, 486 

aloes, 204 

belladonna, 79 

blue mass, 326 

calomel, 209 

cascara sagrada, 199 

castor oil, 208 

colocynth, 212 

compound cathartic pill, 212 

croton oil, 211 

enemata, 197 

enteroclysis, 499 

euonymus, 202 

glycerin suppositories, 467 

ipecac, 271 

magnesia, 199 

magnesium citrate, 219 
sulphate, 217 

oxgall, 204 

phenolphthalein, 208 

physostigma, 148 

podophyllum, 213 

rhubarb, 206 

Rochelle salt, 218 

Seidlitz powder, 219 

senna, 207 

sodium phosphate, 219 

strychnin, 144 

sulphur, 200 

vegetable cathartic pills, 212 



654 



INDEX. 



Constipation 

treatment, 563 
Contusions 

alcohol, 47 

ammonium chloride, 276 

arnica, 444 

camphor, 132 

chloroform, 127 

ichthyol, 335 

lead-water, 364 

opium, 98 

witch-hazel, 364 
Convallamarin, 56 
Convallaria, 56; as a diuretic, 224 
Convulsions 

treatment, 130 
Copaiba, 234 
Copper arsenite, 313 

sulphate, 366 
Coriandrum, 192 
Corn smut, 257 
Corneal opacities 

dionin, 99 
Corns 

acetic acid, 451 

chromic acid, 452 

salicylic acid, 398 

trichloracetic acid, 451 
Corn-silk, 242 
Cornutin, 74, 253 

Corrosive sublimate, 327; as a germi- 
cide, 385 
Coryza. See Rhinitis, acute. 
Cosmolin, 465 

Cotarninae hydrochlorid, 380 
Cotton-root, 257 
Cough 

cannabis indica, 101 

chloroform, 126 

codein, 99 

heroin, 99 

hydrocyanic acid, 160 

hyoscyamus, 81 

opium, 96 
treatment, 267 
Counterirritants, 438 
Cowling's rule for dosage, 38 
Cream of tartar, 227 
Crede's ointment, 374 
Creolin, 391 
Creosotal, 285 
Creosote, 283 
Creosotum, 283 
Cresol, 39 t 
Cresols, 391 
Creta, 377 

Croton chloral. See Butyl-chloral hy- 
drate. 
oil, 206 



Croton-chloral hydrate, 104 

Croup, membranous. See Diphtheria. 

Croup, spasmodic 

treatment, 580 
Cubeba, 235 
Culver's root, 203 
Cumulative action of drugs, 37 
Cupping, 501 
Cupri arsenis, 313 

sulphas, 366; as an emetic, 167 
Curare, 150 
Cusso, 424 
Cycloplegics, 161 
Cystitis, acute 

boric acid, 412 

corn-silk, 242 

hops, 138 

hyoscyamus, 81 

vegetable salts of potassium, 227 
Cystitis, chronic 

benzoic acid, 401 

boric acid (injection), 412 

buchu, 239 

copaiba, 234 

pareira, 241 

silver nitrate (injection), 372 

urotropin, 404 

uva ursi, 241 



Dandelion, 177 
Deadly nightshade, 75 
Decocta, 20 
Decoctions, 20 
Defecation, painful 

belladonna, 79 
Delirium tremens 

apomorphin, 274 

cannabis indica, 101 

chloralamid, 105 

hyoscin, 83, 118 

opium, 96 

paraldehyd, 109 

potassium bromid, 114 
treatment, 46 
Delphinin, 65 
Demulcents, 458 
Deodorizers, 383 
Depilatories, 448 
Dermatol, 376 
Desiccated thyroid extract, 68 

glands, 341 
Dewee's emmenagogue mixture, 249 
Diabetes insipidus 

strychnin, 145 
treatment, 542 
Diabetes mellitus. See also Aceto- 
nemia. 

antipyrin, 350 



INDEX. 



655 



Diabetes mellitus 

arsenic, 310 

bromid, 313 

codein, 99 

gold and sodium chlorid, 336 

jambul, 339 

massage, 486 

opium, 97 

phosphoric acid (thirst), 301 

sodium bicarbonate (coma), 172 

uranium nitrate, 341 
treatment, 539 
Diaphoretics, 257 
Diarrhea, acute 

betanaphthol-bismuth, 395 

bismuth salicylate, 400 
subgallate, 376 
subnitrate, 375 
subsalicylate, 376 

blue mass, 326 

calomel, 210 

camphor, 132 

castor oil, 208 

chalk, 173 

creosote, 284 

Epsom salt, 217 

hematoxylon, 359 

kino, 358 

krameria, 358 

lime-water, 173 

magnesia, 200 

mercury with chalk, 326 

oil of cajuput, 191 

opium, 97 

rhubarb, 206 

salol, 400 

sodium sulphocarbolate, 390 

tannalbin, 356 

tannigen, 356 
treatment, 565 
Diarrhea, chronic 

betanaphthol-bismuth, 395 

bismuth salicylate, 400 

copper sulphate, 367 

iron sulphate, 294 

lead acetate, 364 

silver nitrate, 372 

thymol, 392 

zinc sulphate, 269 
treatment, 568 
Diastase, 184 

Diethylbarbituric acid, in 
Diethylmalonylurea, in 
Digestants, 180 
Digitalin, 48 

Digitalinum germanicum, 48 
Digitalline cristallisee, 48 
Digitalis, 47; as a diuretic, 222; as a 
poison, 49 



Digitophyllin, 48 
Digitoxin, 48 
Dionin, 99 
Diphtheria 

alcohol, 47 

antitoxin, 431 

boric acid, 412 

corrosive sublimate, 328 

hydrogen dioxid, 409 

ice-poultices, 492 

lime-water, 173 

Loffler's solution, 293 

quinin, 419 

strychnin, 143 

tincture of ferric chlorid, 293 
treatment, 523 
Disinfectants, 383 
Disseminated sclerosis 

gold and sodium chlorid, 336 

hyoscyamin, 82 
Diuretics, 220 
Diuretin, 223 
Dobell's solution, 172 
Donovan's solution, 306, 331 
Dosage, 38; Cowling's rule for, 38; 
influence of age, sex, and weight 
on, 38; Young's rule for, 38 
Dover's powder, 92 
Drastics, 195 
Dropsy 

apocynum, 226 

caffein, 223 

calomel, 232 

convallaria, 224 

copaiba, 234 

digitalis, 52, 222 

diuretin, 223 

Epsom salt, 217 

elaterium, 215 

heat, 495 

compound jalap powder, 214 

Niemeyer's pill, 52 

pilocarpin, 260 

scoparius, 225 

Southey's tubes, 611 

squill, 224 

theobromin, 223 

theocin, 223 

vegetable salts of potassium, 226 
Drugs, circumstances modifying effects 

of, 37 . 
composition of, 17 
methods of administering, 35 
preparations of, 19 
Dusting-powders, 459 
Dysentery 

enteroclysis, 498 

hydrogen dioxid, 409 

ice-suppositories, 492 



6;6 



INDEX. 



Dysentery 

ipecac, 270 

magnesium sulphate, 217 

methylene-blue, 421 

opium, 97 

quinin, 419 

silver nitrate, 372 
treatment, 569 
Dysmenorrhea 

antipyrin, 350 

belladonna, 78 

camphor, 132 

cannabis indica, 10 1 

senecio, 249 

viburnum prunifolium, 140 
Dyspepsia. See Indigestion. 

Ecbolics, 251 
Eclampsia, puerperal 

bleeding, 503 

chloral, 103 

chloroform, 126 

hypodermoclysis, 496 

pilocarpin, 260 

potassium bromid, 113 

veratrum, 65 
Eczema, acute 

black wash, 331 

boric acid, 412 

carbolic acid, 390 

hydrocyanic acid, 160 

lead subacetate, 365 

picric acid, 394 

Rontgen rays, 505 

zinc carbonate, 369 
oxid, 368 
Eczema, chronic 

ammoniated mercury, 332 

arsenic, 310 

calomel, 330 

ichthyol, 335 

oil of cade, 445 

resorcin, 393 

salicylic acid, 397 

sulphur, 201 

tar, 288 

thymol, 392 
Ehrlich's lateral-chain theory, 429 
Elaterin, 215 
Elaterium, 215 
Electricity, 475 

static, 475 
Elephantiasis 

thiosinamin, 444 
Elixiria, 21 
Elixirs, 21 
Emetics, 166 
Emetin, 269 
Emmenagogues, 247 



I Emodin, 198, 206 
Emollients, 458 
Emphysema 

ammonium carbonate, 277 

bleeding, 503 

heroin, 99 

quebracho, 274 

strychnin, 143 
treatment, 590 
Emplastra, 29 
Empyema 

treatment, 604 
Emulsa, 24 
Emulsions, 24 
Endermic method of administering 

drugs, 37 
Endocarditis, chronic 

adonidin, 57 

alcohol, 47 

apocynum (dropsy), 226 

belladonna plaster, 79 

bleeding, 503 

caffein, 55 

calomel, 210 

chloralamid (insomnia), 105 

convallaria, 56 

digitalis, 50 

elaterium (dropsy), 215 

Epsom salt (dropsy), 217 

Hoffmann's anodyne, 136 

hyoscin (insomnia), 83 

ice-bag (palpitation), 492 

jalap (dropsy), 214 

massage, 486 

morphin, 96 

Nauheim treatment, 490 

Niemeyer's pill, 52 

nitroglycerin, 71 

paraldehyd (insomnia), no 

squill, 225 

strophanthus, 53 

strychnin, 143 

theobromin, 223 
treatment, 607 
Endometritis 

ichthyol, 335 

iodin, 318 

silver nitrate, 372 

tannic acid, 355 
Enemas, 26, 197 
Enemata, 197 
Enteritis, acute. See Diarrhea, 

acute. 
Enteroclysis, 498 

Enterorrhagia. See Hemorrhage. 
Epididymitis 

guaiacol, 286 

local bleeding, 503 

silver nitrate, 371 



INDEX. 



6$7 



Epilepsy 

acetanilid, 349 

amyl nitrite, 70 

antipyrin, 350 

bromopin, 454 

chloral, 103 

chloretone, 106 

horse-nettle, 131 

hydrobromic acid, 116 

monobromated camphor, 134 

potassium bromid, 113 

urethane, no 
treatment, 635 
Epinephrin, 66 
Epispastics, 438 

Epistaxis. See also Hemorrhage. 
h adrenalin, 68 

antipyrin, 351 

cold, 492 

gelatin, 381 

tannic acid, 355 

vinegar, 451 
Epithelioma 

actinotherapy, 504 

arsenic, 309 

pyrogallol, 453 

Vienna paste, 455 

zinc chlorid, 369 
Epsom salt, 216 
Ergota, 251; as a hemostatic, 378; as a 

poison, 254 
Ergotin, 253 
Erigeron, 239 
Eriodictyon, 471 
Erotomania 

hyoscin, 83 

monobromated camphor, 133 

potassium bromid, 114 
Erysipelas 

Crede's ointment, 374 

grindelia, 283 

ichthyol, 335 

lead-water and laudanum, 198 

tincture of ferric chlorid, 293 
treatment, 534 
Erythema 

bismuth subnitrate, 375 

boric acid, 412 

camphor, 132 

talc, 467 

zinc carbonate, 369 
oxid, 368 
Erythema intertrigo 

bismuth subnitrate, 375 

boric acid, 412 

camphor, 132 

chalk, 377 

starch, 463 

talc, 468 
42 



Erythema intertrigo 

zinc carbonate, 369 
oxid, 368 
Erythrol tetranitrate, 72 
Escharotics, 447 
Eserin, 146; as a myotic, 165 
Essential oils, definition of, 18 
Ether, 118. See JEther. 

compound spirit of, 136 

hydrobromic, 128 

nitrous, spirit of, 260 
Ethyl alcohol, 43 

bromid, 128 

carbamate, no 

chlorid, 129, 158 

oxid, 118 
Eucain, 153 
Eucalyptol, 280 
Eucalyptus, 280 
Eugenol, 188, 191 
Eumydrin, 163 
Euonymin, 202 
Euonymus, 202 
Eupatorium, 177 
Euphthalmin, 164 
Euquinin, 420 
Europhen, 321 
Exalgin, 349 
Excitomotors, 140 
Exodin, 198 
Exophthalmic goiter 
belladonna, 79 

calcium glycerophosphate, 302 
digitalis, 52 
electricity, 483 
ice-bag. 492 
thymus gland, 344 

treatment, 550 
Expectorants, 266 
Extracta, 26 
Extracts, 26 



Faradism, 477 
Febrifuges, 346 
Fel bovis, 203 
Felon 

silver nitrate, 371 
Fennel, 192 
Ferratin, 297 
Ferri carbonas, 292 

chloridum, 292 

citras, 295 

et ammonii sulphas, 295 

hydroxidum, 293 

cum magnesii oxido, 293 

hypophosphis, 297 

iodidum, 295 

lactas, 297 



658 



INDEX. 



Ferri oxalas, 297 
phosphas, 295 
pyrophosphas, 296 
subsulphas, 294 
sulphas, 294 
tartras, 294 
valeras, 135, 297 
Ferrum, 289 

albuminatum, 296 
dialysatum, 293 
reductum, 291 
Fevers 

aconite, 353 
alcohol, 47 
camphor, 132 
chloralamid, 104 
cold, 492 
hops, 139 _ 
hydrobromic acid, 116 
hydrochloric acid, 182 
musk, 137 
pilocarpin, 260 
quinin, 419 
spirit of mindererus, 262 

of nitrous ether, 262 
strychnin, 143 
Fibrolysin, 444 
Filariasis 

methylene-blue, 421 
Filix-mas, 423 

Finsen's light treatment, 504 
Fish berries, 265 
Fixed dressings, 459 

oils, definition of, 18 
Flatulence. See also Tympanites. 
asafetida, 134 
camphor, 132 
capsicum, 186 
carbolic acid, 390 
cardamom, 188 
charcoal, 413 
Hoffmann's anodyne, 137 
oil of cajuput, 190 

of turpentine, 237 
peppermint, 187 
strychnin, 144 
Flavoring agents, 469 
Flaxseed, 459 
Fluidextracts, 23 
Fceniculum, 192 
Formal, 402 
Formaldehydum, 402 
Formalin, 402 
Fowler's solution, 306 
Foxglove, 47 
Frangula, 199 
Franklinism, 475 
Freckles 

lactic acid, 453 



Frenkel's treatment of locomotor ataxia, 

486 
Friar's balsam, 277 
Fruit-sugar, 473 
Fuller's earth, 468 
Fumigation, administering drugs by, 

37 



Galla, 357 

Gall-stones. See Cholelithiasis. 

Galvanism, 475 

Gambir, 358 

Gamboge, 212 

Ganglion 

iodin, 318 
Garlic, 282 
Gastralgia 

ammonia, 42 

arsenic, 310 

bismuth subnitrate, 375 

cannabis indica, 101 

chloroform, 127 

hydrocyanic acid, 160 

menthol, 157 

strontium bromid, 116 
treatment, 558 
Gastrectasis. See Stomach, dilata- 
tion of. 
Gastritis, acute 

bismuth subnitrate, 375 

cerium oxalate, 170 

hydrocyanic acid, 160 

lavage (toxic), 501 

mustard, 443 

opium, 97 

turpentine stupes, 237 
Gastritis, chronic. See Indigestion. 
Gelatin, 380 
Gelseminin, 148 
Gelsemium, 148 
Geni to -urinary tract 

sedatives, 242 

stimulants, 233 
Gentian, 174 
Geranium, 359 
Germicides, 383 
Gin, 43 
Ginger, 189 

Glands, enlarged. See Adenitis. 
Glandulae suprarenales siccas, 66 

thyroidae siccas, 341 
Glandular thymus, 344 
Glauber's salt, 218 
Glaucoma 

arecolin hydrobroma, 165 

eserin, 148 

pilocarpin, 261 
Glonoin, 71. See Nitroglycerin. 



INDEX. 



659 



Glucosids, definition of, 18 
Glutol, 404 
Glycerinum, 466 
Glycerita, 26 
Glycerites, 26 
Glyceryl trinitrate, 71 
Glyceryls nitras, 71 
Glycyrrhiza, 461 
Goa powder, 444 
Goiter 

iodin, 318 

thyroid gland, 343 
Goiter, exophthalmic. See Exoph- 
thalmic goiter. 
Gold and sodium chlorid, 336 
Golden seal, 379 
Gonorrhea. See also Chordee. 

argyrol, 373 

bismuth subnitrate, 376 

copaiba, 234 

copper sulphate, 367 

cubeb, 235 

hydrastin hydrochlorate, 380 

ichthyol, 336 

lead acetate, 364 

methylene-blue, 421 

oil of santal, 236 

picric acid, 394 

potassium permanganate, 409 

salol, 400 

silver nitrate, 372 

soluble salts of silver, 372 
sulphate, 368 
Gossypii cortex, 257 
Goulard's cerate, 365 

extract, 365 
Gout 

arsenic, 310 

colchicum, 337 

guaiac, 338 

lithium salts, 231 

massage, 486 

piperazin, 244 

potassium iodid, 315 

Turkish bath, 495 

uric-acid solvents, 243 

vegetable salts of potassium, 226 
treatment, 542 
Granatum, 423 
Graves' disease. See Exophthalmic 

goiter. 
Green hellebore, 63 
Gregory's powder, 206 
Griffith's mixture, 250 
Grindelia, 283 
Guaiacol, 286 

compounds, 287 
Guaiacolis carbonas, 28$ 
Guaiacum, 338 



Guaiamar, 287 
Gum arabic, 460 
Gum-resins, definition of, 18 
Gums, definition of, 18 
Gurjun balsam, 446 
Gutta-percha, 469 



FLematoxylon, 359 
Hair, superfluous 

barium sulphid, 456 

calcium sulphid, 456 

hydrogen peroxid, 409 
Hamamelis, 360 
Hands, disinfection of, 385 
Haptophore groups, 429 
Hashish, 100 
Hay fever. See also Asthma. 

adrenalin, 68 

cocain, 88 
Hay's treatment of serous effusions, 602 
Headache 

acetanilid, 349 

antipyrin, 350 

caffein, 55 

calcium chlorid, 383 

ergot, 256 

hydrobromic acid, 116 

hot foot-bath, 495 

ice-cap, 492 

menthol, 158 

mustard plaster, 441 

phenacetin, 351 

potassium bromid, 114 

quinin (malarial), 417 
Heart, degeneration of 

arsenic, 310 

caffein, 55 

digitalis, 51 

massage, 486 

Nauheim treatment, 488 

nitroglycerin, 71 

strophanthus, 53 

strychnin, 143 
treatment, 613 
Heart, hypertrophy of 

aconite, 62 

veratrum viride, 64 
Heartburn 

antacids, 170 
Heart-failure, sudden. See Collapse. 
Heat, 493 
Hedeoma, 251 
Hedonal, in 
Hellebore, 63 
green, 63 
white, 63 
Hematemesis. See Hemorrhage. 
Hematogen, 296 



66o 



INDEX. 



Hematoxylon, 359 
Hemlock, 151 
Hemogallol, 297 
Hemol, 297 
Hemophilia 

calcium chlorid, 385 

gelatin, 381 
treatment, 549 
Hemoptysis. See Hemorrhage. 
Hemorrhage 

acetic acid, 451 

adrenalin, 68 

alum, 361 

ammonio-ferric alum, 295 

amyl nitrite, 70 

antipyrin, 351 

calcium chlorid, 383 

cold, 492 

enteroclysis, 499 

ergot, 378 

ferric chlorid, 292 

gelatin, 381 

hydrastinin, 380 

hypodermoclysis, 496 

infusion, 496 

Monsel's solution, 294 

nitroglycerin, 72 

oil of erigeron, 239 
of turpentine, 237 

opium, 97 

stypticin, 380 

tannic acid, 355 

witch-hazel, 360 
treatment, 377 
Hemorrhoids 

adrenalin, 68 

anesthesin, 157 

belladonna, 79 

calcium chlorid, 383 

iodoform, 321 

nutgall ointment, 358 

stramonium ointment, 81 

sulphur, 201 

witch-hazel, 360 
Hemostatics, 377 
Hemp, Canadian, 225 

Indian, 100 
Henbane, 81 
Heroin, 99 
Herpes zoster 

picric acid, 394 

zinc oxid, 368 
Hexamethylenamina, 404 
Hiccough 

camphor, 132 

Hoffmann's anodyne, 136 

musk, 137 

nitroglycerin, 71 

oil of amber, 140 



Hoffmann's anodyne, 136 

Holocain, 153 

Homatropin hydrobromid, 163 

Honey, 474 

Honeys, 25 

Hook-worm disease 

betanaphthol, 395, 427 
thymol, 392, 427 
Hops, 138 
Horse -nettle, 131 
Hot baths, 494 

pack, 494 
Humulus, 138 
Huxham's tincture, 415 
Hydragogues, 195 

Hydrargyri chloridi corrosivum, 327* 
as a germicide, 385 
mite, 330; as a cathartic, 209; as 
a diuretic, 232 
cyanidum, 332 
iodidum flavum, 331 

rubrum, 331 
nitras, 332; as a caustic, 455 
oxidi flavi, 333 

rubric 333 
salicylas, 333 
subsulphas, 167, 333 
succinimidum, 334 
unguentum, 327 
Hydrargyrum, 322 
ammoniatum, 332 
cum creta, 210, 326 
Hydrastin, 379 
Hydrastina, 379 
Hydrastinin, 379 
Hydrastis, 379; as an oxytocic, 256; as 

a stomachic, 180 
Hydrocyanic acid, 160 
Hydrogen dioxid, 408 
Hyoscin, 75, 163 

hydrobromid, 82, 117 
Hyoscina, 81 

Hyoscinae hydrobromidum, 117 
Hyoscyamin, 75, 82 
Hyoscyamina, 82 
Hyoscyamus, 81 
Hyperchlorhydria 
lavage, 501 

sodium bicarbonate, 172 
Hyperemesis. See Vomiting, excess- 
ive. 
Hyperidrosis. See also Niglit-sweats. 
agaricin, 264 
alum, 361 
belladonna, 78 
chromic acid, 452 
formaldehyd, 404 
lead-plaster, 365 
salicylic acid, 397 



INDEX. 



66 1 



Hyperidrosis 

sulphuric acid, 449 

tannic acid, 355 

tannofarm, 356 
Hypertrichosis 

Rontgen rays, 505 
Hypnotics, 89 
Hypodermic method of administering 

drugs, 35 
Hypodermoclysis, 496 
Hypophysis cerebri, 345 
Hysteria 

asafetida, 134 

bromids, 114 

camphor, 132 

chloralamid, 105 

cold bath, douche, or spray, 493 

electricity, 482 

gold and sodium chlorid, 336 

massage, 486 

monobromated camphor, 134 

paraldehyd, 109 

sumbul, 139 

valerian, 135 
treatment, 642 

Ice-poultice, 490 
Ichthalbin, 335 
Ichthargan, 335 
Ichthoform, 335 
Ichthyol, 334 
Ichthyosis 

thyroid gland, 343 
Idiosyncrasy, 37 
Immune body, 430 
Impotence 

phosphorus, 300 

strychnin, 145 

yohimbin, 245 
treatment, 245 
Incompatibilities, 30 
Incontinence of urine 

belladonna, 78 

strychnin, 144 
Index, opsonic, 430 
Indian hemp, 100 
Indigestion 

alcohol, 180 

arsenic, 310 

asafetida, 134 

bismuth subgallate, 376 
subnitrate, 375 

calomel, 210 

capsicum, 186 

carbolic acid, 390 

charcoal, 413 

creosote, 284 

enteroclysis, 498 

gentian, 175 



Indigestion 

hydrastis, 180 

hydrochloric acid, 181 

ipecac, 271 

lavage, 501 

lime-water, 173 

nitrohydrochloric acid, 450 

nux vomica, 144 

pancreatin, 183 

pepsin, 183 

rhubarb, 207 

silver nitrate, 372 

sodium bicarbonate, 171 
sulphocarbolate, 390 

stomachics, 174 

strontium bromid, 116 
treatment, 565 
Infiltration anesthesia, 86 
Influenza 

antipyrin, 350 

cinnamon, 190 

Dover's powder, 271 

quinin, 419 
treatment, 517 
Infusa, 20 
Infusion, 496 
Infusions, 20 

Inhalation, administering drugs by, 37 
Insomnia 

cannabis indica, 10 1 

chloral, 103 

chloralamid, 105 

chloralose, 106 

chloretone, 106 

hedonal, 111 

hyoscin, 83 

opium, 96 

paraldehyd, no 

sulphonal, 108 

trional, 109 

urethane, no 

veronal, in 
treatment, 90 
Intertrigo. See Erythema intertrigo. 
Intravenous injection of drugs, 36 
Intussusception 

enteroclysis, 499 
Inunction, administering drugs by, 36 
Iodin, 317 
Iodipin, 319 
Iodism, 314 

Iodoformum, 319; as a local anesthetic, 
159; as an antiseptic, 384; as a poison 

3*9 

Iodol, 321 
Iodothyrin, 342 
Iodum, 317 
Ipecacuanha, 269 
as an emetic, 167 



662 



INDEX. 



Iris, 202 
Iritis 

adrenalin, 68 

atropin, 79 

dionin, 99 

eserin, 148 

local bloodletting, 503 

mercury, 330 
Iron, 289 

albuminates, 296 
ammonium sulphate, 295 
carbonate, 291 
chlorid, 292 
citrate, 295 
dialyzed, 293 
hydroxid, 293 
hypophosphite, 297 
iodid, 295 
lactate, 297 
oxalate, 297 
phosphate, 296 
pyrophosphate, 296 
Quevenne's, 291 
reduced, 291 
subsulphate, 294 
sulphate, 294 
tartrate, 294 
valerate, 135, 297 
Irritants, 438 
Itch. See Scabies. 
Itrol, 373 
Ivy-poisoning. See Rhus-poisoning. 



Jaborandi, 258 
Jalapa, 213 
Jambul, 339 
Jamestown weed, 80 
Jasmine, yellow, 149 
Jaundice, catarrhal 

ammonium chlorid, 276 

boric acid (pruritus), 412 

carbolic acid (pruritus), 389 

enteroclysis, 499 

hydrocyanic acid (pruritus), 160 

sodium phosphate, 219 

vegetable salts of potassium, 226 
Jequirity, 447 

Joints, inflammation of. See Ar- 
thritis. 
Juglans, 202 
Juniperus, 239 



Kamala, 425 
Kaolinum, 468 
Keloid 

thiosinamin, 443 



Keratitis 

atropin, 79 

boric acid, 412 

dionin, 99 

eserin, 148 

formaldehyd, 404 

holocain, 155 

mercuric oxid, 333 

pilocarpin, 261 
Kidneys, inflammation of. See 

Nephritis. 
Kino, 358 

Kousso, 424 " . 

Krameria, 358 
Kryofin, 352 



Labarraque's solution, 407 

Laborde's method in asphyxia, 73 

Lactophenin, 352 

Lactose, 472 

Lactucarium, 138 

Lady Webster's pills, 204 

Lanolin, 464 

Largin, 373 

Laryngismus stridulus 

belladonna, 78 

gelsemium, 149 

musk, 137 

potassium bromid, 113 
Laryngitis, acute 

aconite, 62 

benzoin inhalations, 278 

creosote, 284 

iodin (externally), 318 

menthol, 158 
treatment, 580 
Laryngitis, chronic 

alum, 361 

menthol, 158 

silver nitrate, 372 

tannic acid, 355 
treatment, 581 
Laryngitis, tuberculous 

anesthesin, 157 

cocain, 154 

guaiacol, 286 

iodoform, 320 

lactic acid, 452 

morphin, 96 

orthoform, 156 
treatment, 582 
Laudanum, 91 
Lavage, 500 
Lavandula, 472 
Lavender, 472 
Laxatives, 193 
Lead, 362 
acetate, 364 



INDEX. 



663 



Lead iodid, 317 
nitrate, 365 
oleate of, 365 
oxid, 366 
subacetate, 365 
Lead-poisoning 
treatment, 363 
Lead-water and laudanum, 364 
Leeching, 507 
Leiter's tubes, 490 
Lemon, 469 
Leprosy 

chaulmoogra oil, 446 
gurjun balsam, 446 
Leptandra, 203 
Lettuce, wild, 138 
Leukorrhea 
alum, 295 

ammonio-ferric alum, 361 
belladonna, 78 
hydrastis, 380 
ichthyol, 335 
oak bark, 360 
tannic acid, 355 
zinc sulphate, 368 
Leukemia 

Rontgen rays, 506 
treatment, 548 
Levulose, 473 
Licorice root, 461 
Lily of the valley, 56 
Lime, 410 

chlorinated, 406 
sulphurated, 340 
Lime-water, 172 
Limon, 469 
Linimenta, 25 
Liniments, 25 
Linseed, 459 
Linum, 459 

Liquor antisepticus, 411 
calcis, 172 

cresolis compositus, 391 
gutta-perchae, 469 
Liquores, 19 
Litharge, 366 
Lithii benzoas, 232 
bromidum, 116 
carbonas, 231 
citras, .232 
salicylas, 398 
Liver, cirrhosis of 

treatment, 575 
Lobelia, 151 

as an expectorant, 275 
Locomotor ataxia 
antipyrin, 350 
cannabis indica, 101 
electricity, 482 



Locomotor ataxia 

Frenkel's exercises, 486 

gold and sodium chlorid, 336 

opium, 96 
treatment, 625 
Ldffler's solution, 295 
Logwood, 359 
Lotio flava, 330 

nigra, 331 
Lotiones, 25 
Lotions, 25 
Lozenges, 28 
Lugol's solution, 317 
Lumbago. See Muscular rheumatism. 

antipyrin, 350 

acupuncture, 438 

cimicifuga, 138 

electricity, 483 

salicylic compounds, 397 
Lumbar puncture, 507 
Lunar caustic, 370 
Lungs, edema of. See also Dropsy. 

belladonna, 78 

caffein, 55 
. local bloodletting, 503 

strychnin, 144 
Lungs, tuberculosis of. See also 

Tuberculosis, pulmonary. 
Lupulinum, 138 
Lupus vulgaris 

actinotherapy, 504 

arsenic, 309 

lactic acid, 452 

pyrogallol, 453 

Rontgen rays, 505 

thiosinamin (scarring), 444 
Lycetol, 244 
Lycopodium, 468 
Lysidin, 244 
Lysol, 392 



Magnesia, 199 

as an antacid, 173 
Magnesii carbonas, 200 
citras, 219 
oxidum, 173, 199 

ponderosum, 173, 20c 
sulphas, 216 

effervescens, 216 
Magnesium oxid, 199 
Malarial fever 

amyl nitrite (chills), 70 
arsenic, 310 
methylene-blue, 421 
quinin, 417 

Warburg's tincture, 262 
treatment, 516 
Male fern, 423 



664 



INDEX. 



Mandrake, 213 

Mangani dioxidum praecipitatum, 248 

Manganum, 248 

Mania 

cannabis indica, 10 1 

chloral, 103 

conium, 151 

croton oil, 211 

hyoscin, 83, 118 

nrethylene-blue, 420 

paraldehyd, 109 
Manna, 198 
Marshmallow, 461 
Massa hydrargyri, 210, 326 
Massae, 27 
Massage, 484 
Masses, 27 

Materia medica, definition of, 17 
Matico, 235 
May apple, 212 
Measles 

treatment, 527 
Medullary cocainization, 87 
Mel, 474 
Melaena neonatorum 

gelatin, 381 
Melancholia 

hyoscin, 118 
Mellita, 25 
Meniere's disease 

gelsemium, 149 

pilocarpin, 261 
Meningitis, acute 

ice-cap, 492 

local bleeding, 503 

lumbar puncture, 507 

opium, 96 
treatment, 515 
Meningitis, cerebrospinal 

treatment, 515 
Menorrhagia 

cimicifuga, 138 

ergot, 255 

hydrastinin, 380 

stypticin, 380 
Mentha piperita, 187 

viridis, 187 
Menthol, 157 
Mercurial ointments, 327 
Mercuric chlorid, 327; as a germicide, 

385 
cyanid, 332 
nitrate, 332 
oxici, 333 
salicylate, 333 
sulphate, 333 
succinimid, 334 
Mercurous chlorid, 330; as a cathartic, 
209; as a diuretic, 232 



Mercury, 322 
ammoniated, 332 
bichlorid, 327 
biniodid, 331 
cyanid, 332 
nitrate, 332 
oxid, 333 
protiodid, 331 
salicylate, 334 
subsulphate, 167,-333 
with chalk, 326 
Mercury-poisoning, 322 
Mesotan, 399 
Metacresol, 391 
Methylaldehyd, 402 
Methylatropin, 163 
Methyl-blue, 414 
Methylene-blue, 420 
Methylis salicylas, 399 
Methylpropylcarbinolurethane, 1 1 1 
Methylthionin hydrochlorid, 420 
Metric system, 645 
Metrorrhagia 
ergot, 255 
gelatin, 381 
hydrastinin, 380 
stypticin, 381 
thyroid gland, 343 
Mezereum, 340 

Migraine. See also Neuralgia. 
amyl nitrate, 70 
antipyrin, 350 
butyl-chloral hydrate, 104 
caffein, 55 

cannabis indica, 10 1 
ergot, 256 

methylene-blue, 484 
nitroglycerin, 72 
potassium bromid, 114 
Mindererus, spirit of, 262 
Misturae, 20 
Mixture, Basham's, 292 
brown, 462 
Dewees's, 249 
Griffith's, 249 
neutral, 228 
Mixtures, 20 
Monkshood, 60 
Monsel's salt, 294 

solution, 294 
Moore-Corradi treatment of aneurysm, 

483 
Morphin, 91 
Morphinism, 95 

Moschus, 137 

Motor nerve depressants, 150 

Mouth, administering drugs by, 35 

Mucilages, 20 

Mucilagines, 20 



INDEX. 



665 



Mucous patches 

chromic acid, 452 

mercuric nitrate, 332 

potassium chlorate, 230 

silver nitrate, 372 

trichloracetic acid, 451 
Mumps 

treatment, 538 
Musk, 137 
Musk-root, 139 

Mustard, 168; as a counterirritant, 442 
Myalgia. See Rheumatism, muscular. 
Mycosis fungoides 

Rontgen rays, 505 
Mydriatics, 161 
Myelitis 

treatment, 627 
Myotics, 165 
Myristica, 189 
Myrrha, 250 
Myrtol, 281 
Myxedema 

thyroid extract, 343 

Naphthalinum, 394 
Narcein, 91 
Narcotin, 91 
Nativelle's digitaline, 48 
Nauheim treatment, 488 
Nephritis, acute. See also Dropsy 
and Uremia. 

Basham's mixture, 293 

cupping, 503 

digitalis, 222 

hot baths, 485 

pilocarpin, 260 

vegetable salts of potassium, 227 
treatment, 616 
Nephritis, chronic. See also Dropsy 
and Uremia. 

apocynum (dropsy), 226 

Basham's mixture, 293 

caffein (dropsy), 223 

digitalis, 222 

heat, 495 

erythrol tetranitrate, 72 

nitroglycerin, 71 

pilocarpin, 260 

potassium iodid, 315 

theobromin, 223 
treatment, 618 
Nephrolithiasis 

lycetol, 244 

piperazin, 244 

piperidin tartrate, 244 

quinic acid, 244 

vegetable salts of potassium, 227 
treatment, 622 
Nerve depressants, 150, 153 



Neuralgia 

acetanilid, 349 

aconitin, 63 

antipyrin, 350 

arsenic, 310 

blisters, 441 

butyl-chloral hydrate, 104 

cannabis indica, 10 1 

chloral camphor, 103 

electricity, 482 

gelsemium, 149 

menthol, 157 

methylene-blue, 420 

opium, 96 

osmic acid, 453 

phenacetin, 351 

phosphorus, 300 

potassium bromid, 114 

quinin, 419 

strychnin, 145 

veratrin, 65 
Neurasthenia 

calcium glycerophosphate, 302 

cold douche or spray, 493 

electricity, 482 

gold and sodium chlorid, 336 

hydrotherapy, 493 

massage, 486 

orexin, 179 

phosphorus, 300 

strychnin, 144 

sumbul, 139 
treatment, 639 
Neuritis 

blisters, 441 

cautery, 438 
■ electricity, 481 

iodin, 318 

massage, 485 

salicylic compounds, 395 

strychnin, 144 
treatment, 629 
Neutral mixture, 228 

principles, definition of, 19 
Nevi 

sodium ethylate, 456 

trichloracetic acid, 451 
Niemeyer's pill, 52 
Night-sweats 

antihydrotics, 263 
Nipples, fissured 

benzoin, 278 

collodion, 469 

glycerin, 467 

orthoform, 156 
Nitrites, 69 

Nitrogen monoxid, 127 
Nitroglycerin, 71; action of, 71; as a 
circulatory stimulant, 57 



666 



INDEX. 



Nitrous ether, spirit of, 262 

oxid, 127 
Nosophen, 322, 391 
Novocain, 157 
Nutgall, 357 
Nutmeg, 189, 

Nux vomica, 141; as a poison, 142; as 
a circulatory stimulant, 30; as a 
stomachic, 180 
Nymphomania 

camphor, monobromated, 134 
hyoscin, 81 
potassium bromid, 114 

Oak, white, 360 
Obesity 

thyroid gland, 343 
Oil, amber, 140 

birch, 399 

cade, 445 

cajuput, 190 

carron, 172 

castor, 208 

chaulmoogra, 445 

cod-liver, 303 

croton, 211 

erigeron, 239 

eucalyptus, 280 

gaultheria, 399 

juniper tar, 445 

myrtle, 281 

santal, 236 

tar, 287 

turpentine, 236; as an expectorant 
289; as a counterirritant, 446; as 
an anthelmintic, 427 
Ointment, blue, 327 
Ointments, 28 

of mercury, 327 
Oleate of lead, 365 
Oleates, 29 
Oleatum plumbi, 365 
Oleoresins, definition of, 18 
Oleum betulae, 399 

cadinum, 445 

cajuputi, 190 

cubebse, 235 

erigerontis, 239 

gaultheriae, 399 

gynocardiae, 445 

morrhuae, 303 

myrti, 281 

olivae, 464 

ricini, 208 

santali, 236 

succini, 140 

terebinthinae, 236; as an anthelmin- 
tic, 427; as a counterirritant, 446; 
as an expectorant, 289 



Oleum tiglii, 211 
Onychia 

lead nitrate, 366 
Opium, 91; as an anti-emetic, 170; as a 

diaphoretic, 261; as a poison, 94 
Opium-pfiisoning 

artificial respiration, 73 

atropin, 80 

caffein, 55 

cocain, 88 

electricity, 483 

lavage, 501 

potassium permanganate, 409 

strychnin, 143 

tannic acid, 356 
treatment, 94 
Opsonic index, 430 
Opsonins, 430 
Orange, 470 
Orchitis 

belladonna ointment, 79 

guaiacol, 286 

local bloodletting, 503 

mercury and belladonna ointment, 

327 
Orexin, 179 
Organic acids, 19 
Orphol, 395 
Orthocresol, 391 
Orthoform, 155 
Osteomalacia 

calcium phosphate, 302 

phosphorus, 300 
Otorrhea 

boric acid, 412 

formaldehyd, 404 
Ovarium, 345 
Oxgall, 203 
Oxytocics, 251 
Ozena. See Rhinitis, chronic. 



Pack, cold, 491 

hot, 494 
Palpitation 

belladonna, 79 

digitalis, 52 

Hoffmann's anodyne, 136 

ice-bag, 492 
Palpitation, abdominal 

nitroglycerin, 71 
Pancreatinum, 183 
Papain, 184 
Papayotin, 184 
Papers, 30 
Papoid, 184 
Paracresol, 391 
Paraffin, 465 
Paraform, 402 



INDEX. 



667 



Paraformaldehyd, 402 
Paraldehydum, 109 
Paralysis agitans 

conium, 151 

hyoscin, 83 

hyoscyamin, 82 
Paregoric, 91 
Paresis, postoperative, intestinal 

physostigma, 148 
Pareira brava, 241 
Parsley, 248 
Pearson's solution, 306 
Pediculosis capitis 

ointment of stavesacre, 65 

tincture of cocculus indicus, 265 
Pediculosis pubis 

blue ointment, 327 

corrosive sublimate, 328 
Pelletierin, 423 
Pemphigus 

arsenic, 310 
Pennyroyal, 251 
Pepo, 425 
Pepper, black, 186 

cayenne, 185 
Peppermint, 187 
Pepsinum, 182 
Pericarditis 

blisters, 441 

calomel, 330 

iodin, 318 

local bloodletting, 503 

potassium iodid, 315 
treatment, 604 
Pernicious anemia 

treatment, 547 
Peronin, 100 

Pertussis. See Whooping-cough. 
Peruvian bark, 415 
Petrolatum, 465 

Pharmacodynamics, definition of, 17 
Pharmacy, definition of, 17 
Pharyngitis, acute 

aconite, 62 

capsicum, 186 

potassium chlorate, 230 

rhus glabra, 359 

sodium benzoate, 278 

tincture of ferric chlorid, 293 
treatment, 552 
Pharyngitis, chronic 

alum, 361 

ammonium chlorid, 275 

D obeli's solution, 172 

iodin, 319 

silver nitrate, 372 

tannic acid, 355 

tincture of ferric chlorid, 293 
treatment, 553 



Phenacetin, 351 

Phenazon, 350 

Phenocoll hydrochlorid, 352 

Phenol, 387. See also Carbolic acid. 

Phenolphthalein, 208 

Phenylis salicylas, 400 

Phlebitis, acute 

Crede's ointment, 374 
Phlebotomy, 503 

Phosphorus, 298; as a poison, 298 
Phosphorus-poisoning 
copper sulphate, 367 

treatment, 299 
Phthisis. See Tuberculosis, pulmo- 
nary. 
Physostigma, 146 

as a myotic, 165 
Physostigmin, 146 
Picrotoxin, 74 
Picrotoxinum, 265 
Pills, 27 

Blaud's, 292 

blue, 326 

compound cathartic, 212 

Lady Webster's, 204 

Niemeyer's, 52 

Plummer's, 209 

vegetable cathartic, 212 
Pilocarpin, 258; as a myotic, 165 
Pilocarpus, 258 
Pilulse, 27 
Pimenta, 191 
Pinkroot, 426 
Piper, 186 
Piperazin, 244 
Piperidin tartrate, 244 
Piperin, 187 
Pituitary body, 345 
Pix liquida, 287 
Plasters, 30 
Pleurisy 

treatment, 601 
Plumbi acetas, 364 

iodidum, 317 

nitras, 365 

oxidum, 366 

subacetas, 365 
Plumbum, 362 
Plummer's pills, 209 
Pneumonia, catarrhal 

treatment, 591 
Pneumonia, croupous 

ammonium carbonate, 277 

antipneumococcic serum, 434 

belladonna, 78 

bleeding, 503 

blisters, 441 

caffein, 55 

camphor, 132 



668 



INDEX. 



Pneumonia, croupous 

cocain, 88 
digitalis, 52 
hypodermoclysis, 496 
ice-bag, 492 
musk, 137 
strychnin, 143 
veratrum, 65 
treatment, 519 
Podophyllum, 213 
Poliomyelitis 

electricity, 482 
massage, 485 
strychnin, 144 
treatment, 628 
Pollantin, 437 
Pomegranate, 423 
Porter, 44 
Potassii acetas, 228 
bicarbonas, 227 
bitartras, 227 
bromidum, in; as an anaphrodisiac, 

246; as a somnifacient, in 
carbonas, 227 
chloras, 229 

citras, 228; as an expectorant, 275 
dichromas, 452 
et sodii tartras, 218 
hydroxidum, 454 
iodidum, 313 
nitras, 228 

permanganas, 409; as an emmena- 
gogue, 248 
Potassium dichromate, 452 
hydroxid, 454 

vegetable salts of, 226; as expec- 
torants, 275 
Poultices, 30 

Powder, compound jalap, 214 
licorice, 207 
Dover's, 269 
Gregory's, 206 
Seidlitz, 218 
Powders, 27 

Preparation of drugs, 19 
Priapism 

hyoscin, 81 

monobromated camphor, 134 
potassium bromid, 114 
treatment, 627 
Protargol, 373 
Protectives, 458 
Protoveratrin, 63 
Prunus Virginiana, 178 
Pruritus 

boric acid, 412 
camphorated chloral, 103 
carbolic acid, 159 
creosote, 285 



Pruritus 

hydrocyanic acid, 160 

ichthyol, 335 

resorcin, 393 

RCntgen rays, 505 

thymol, 392 
Prussic acid, 160 
Pseudoleukemia 

Rontgen rays, 506 
Psoriasis 

ammoniated mercury, 332 

arsenic, 310 

chrysarobin, 445 

oil of cade, 445 

pyrogallol, 453 

sulphur, 201 

tar, 288 

thyroid gland, 343 
Ptyalism. See Mercury-poisoning. 
Puerperal eclampsia. See Eclamp- 
sia, puerperal. 
Pulsatilla, 65; as an emmenagogue, 251 
Pulveres, 27 

Pulvis effervescens compositus, 218 
Pumpkin seed, 425 
Punicin, 423 
Purgative, 198 
Purgatives, 195 
Purgen, 208 
Purpura haemorrhagica 

calcium chlorid, 383 

gelatin, 381 

oil of turpentine, 237 
treatment, 549 
Pyoktanin, 414 
Pyrogallol, 452 



Quassia, 175 
Quebracho, 274 
Quercus, 360 

alba, 360 
Quevenne's iron, 291 
Quicklime, 410 
Quicksilver, 322 

Quincke's lumbar puncture, 507 
Quinic acid, 244 
Quinina, 416; as antipyretic, 352; as 

oxytocic, 256; as stomachic, 180 



Rachitis 

calcium phosphate, 302 
cod-liver oil, 304 
ferrous iodid, 295 
phosphorus, 300 
thymus gland, 345 

Radium, 506 

Ragwort, 249 



INDEX. 



669 



Raynaud's disease 

erythrol tetranitrate, 72 

nitroglycerin, 72 
Receptors, 429 

Rectum, administering drugs by, 36 
Relapsing fever 
treatment, 514 
Renal calculus. See Nephrolithiasis. 
Resina, 238 

Resins, definition of, 18 
Resorcinol, 393 
Respiration, artificial, 73 
Respiratory depressants, 74 

stimulants, 73 
Rhamnus purstuana, 198 
Rheum, 206 
Rheumatism, acute 

blue ointment, 327 

ferrous iodid, 295 

ice-pack (hyperpyrexia), 493 

ichthyol, 335 

iodin, 318 

iron iodid, 295 

lead-water and laudanum, 366 

oil of gaultheria, 400 

opium, 98 

salicylic compounds, 397 

vegetable salts of potassium, 226 
treatment, 536 
Rheumatism, chronic 

ammonia liniment, 42 

arsenic, 310 

cimicifuga, 138 

cod-liver oil, 304 

Donovan's solution, 331 

dry heat, 495 

guaiac, 338 

iodin, 318 

massage, 486 

potassium iodid, 315 

salicylic compounds, 397 

serpentaria, 178 

sulphur, 201 

Turkish bath, 495 
treatment, 544 
Rheumatism, muscular 

aconite liniment, 63 

ammonia liniment, 42 

belladonna ointment or plaster, 79 

camphor liniment, 133 

capsicum liniment, 186 

chloroform liniment, 127 

cimicifuga, 138 

Dover's powder, 261 

electricity, 483 

opium, 97 

pilocarpin, 260 

salicylic compounds, 397 

turpentine liniment, 237 



Rheumatism, muscular 

treatment, 545 
Rheumatoid arthritis 

arsenic, 310 

cod-liver oil, 304 

guaiacol carbonate, 287 

hot air, 496 

massage, 486 

potassium iodid, 315 
treatment, 545 
Rhinitis, acute 

adrenalin, 68 

camphor, 133 

cocain, 88 

Dover's powder, 271 

hot foot-bath, 495 

menthol, 158 

witch-hazel, 360 
treatment, 577 
Rhinitis, chronic 

chromic acid, 452 

citric acid (pzena), 470 

Dobell's solution, 172 

eucalyptol, 281 

ichthyol (atrophic), 335 

iodin, 319 

menthol, 157 

potassium permanganate, 409 
treatment, 578 
Rhubarb, 206 
Rhus glabra, 359 
Rhus-poisoning 

black wash, 331 

grindelia, 283 

sodium hyposulphite, 410 

zinc carbonate, 369 
Ricin, 208 

Rickets. See Rachitis. 
Ringworm 

ammoniated mercury, 332 

beta-naphthol, 395 

chrysarobin, 445 

corrosive sublimate, 328 

Rontgen rays, 505 

sodium hyposulphite, 410 

sulphur, 201 

sulphurous acid, 407 
I Rochelle salt, 218 
Rontgen ray therapy, 505 
Rooms, disinfection of, 387 
Rosa, 472 
Rosin, 238 
Rottlera, 425 
Rubefacients, 438 
Rubella 

treatment, 527 
Rue, 252 

Russian bath, 494 
Ruta, 252 



670 



INDEX. 



Sabina, 251 
Saccharin, 473 
Saccharum lactis, 472 
Sal ammoniac, 275 
Salicinum, 401 
Salines as diuretics, 220 
Salivation 

atropin, 78 

hydrogen dioxid, 409 

myrrh, 250 

potassium chlorate, 231 

rhus glabra, 359 
Salol, 400 
Salophen, 401 
Saltpeter, 228 
Sandalwood, oil of, 236 
Sanguinaria, 282 
Santoninum, 425 
Sapo mollis, 459 
Saponins, definition of, 19 
Sarsaparilla, 339 
Sassafras, 191, 461 
Savine, 251 
Scabies 

balsam of Peru, 279 

beta-naphthol, 395 

sulphur, 201 
Scalds. See Bums. 
Scammonium, 213 
Scarlet fever 

treatment, 525 
Scheele's green, 313 
Schleich's infiltration anesthesia, 86 
Schott treatment, 488 
Sciatica 

actual cautery, 438 

acupuncture, 438 

antipyrin, 350 

blisters, 441 

cimicifuga, 138 

massage, 486 

methylene-blue, 421 

nitroglycerin, 72 

salicylic compounds, 397 
treatment, 630 
Scilla, 224; as an expectorant, 288 
Scleroderma 

thiosinamin, 445 
Scoparin, 225 
Scoparius, 225 
Scopola, 81 
Scopolamin, 81 

hydro bromid, 81, 163 
Secale cornutum, 252 
Scurvy 

treatment, 548 
Sea-sickness 

chloralamid, 105 

chloretone, 106 



Sea-sickness 

potassium bromid, 114 
Seborrhea 

resorcin, 393 
sulphur, 201 
Seidlitz powder, 218 
Senecio, 249 
Senega, 281 
Senna, 207 

Sensory nerve depressants, 153 
Serpentaria, 178 
Serum, anti-anthrax, 436 
antidiphthericum, 431 
antidysenteric, 437 
antimeningococcic, 434 
antipneumococcic, 434 
antistreptococcus, 429 
antituberculous, 435 
antityphoid, 437 
bubonic plague, 436 
Shock 

adrenalin, 68 
alcohol, 47 
ammonia, 42 
atropin, 78 
adrenalin, 59 
enteroclysis, 498 
ether, 57 
hot bath, 495 
hypodermoclysis, 496 
infusion, 496 
strychnin, 143 
Sidonal, 244 
Silver, 369 
citrate, 373 
colloidal, 374 
lactate, 373 
nitrate, 370 
oxid, 370 

soluble salts of, 372 
vitellin, 373 
Sinapis alba, 442 

nigra, 442 
Sleeping sickness 

atoxyl, 312 
Slippery elm, 461 
Small-pox 

treatment, 528 
Snake-bite. See Bites, snake-. 
Snakeroot, black, 137 

Virginia, 378 
Soap, green, 459 
Soapstone, 467 
Soda, caustic, 455 
Sodii, arsenas, 306 
benzoas, 278 
bicarbonas, 171 
boras, 412 
bromidum, 115 



INDEX. 



671 



Sodii cacodylas, 312 

ethylas, 456 

hydroxidum, 456 

iodidum, 316 

nitris, 73 

phenolsulphonas, 390 

phosphas, 219 

salicylas, 398 

sulphas, 218 

thiosulphas, 410 
Sodium hydroxid, 455 

nitrite, 73 

sulphocarbolate, 390 
Solanum carolinense, 131 
Solutions, 19 
Somnifacients, 89 
Southey's tubes, 611 
Sozoiodol, 390 
Spanish flies, 440; as an emmenagogue, 

249; as a stimulant to genito-urinary 

tract, 441 
Spartein, 152, 225 
Sparteinae sulphas, 152 
Spearmint, 187 
Spermaceti, 464 
Spermatorrhea 
hops, 139 
hyoscin, 83 

monobromated camphor, 134 
potassium bromid, 114 

treatment, 244 
Sphacelotoxin, 253 
Spice -poultice, 189 
Spigelia, 426 
Spinal cord depressants, 145 

excitants, 140 
Spirit of mindererus, 262 

of nitrous ether, 262; as a diuretic, 

233 
Spirits, 21 
Spiritus, 21 

aetheris compositus, 135 

glycerylis nitratis, 71 

nitrosi, 262; as a diuretic, 233 
Sprains 

arnica, 444 

camphor liniment, 133 

capsicum, 186 

chloroform liniment, 127 

dry heat, 495 

ichthyol, 335 

lead-water, 364 

massage, 486 

opium, 98 

witch-hazel, 360 
Sputum, disinfection of, 388 
Squill, 224; as an expectorant, 288 
Staphisagria, 65 
Starch, 463 



Stavesacre, 65 

Stereoptenes, definition of, 18 

Sterility 

thyroid gland, 343 
Stomach, cancer of. See also Vom- 
iting, excessive. 

bismuth subnitrate, 375 

cerium oxalate, 170 

condurango, 177 

creosote, 285 

gentian, 175 

hydrochloric acid, 182 

hydrocyanic acid, 160 

opium, 95 
treatment, 561 
Stomach, chronic catarrh of. See 

Indigestion. 
Stomach, dilatation of. See also 
Indigestion. 

gastric antiseptics, 386 

lavage, 501 

olive oil, 465 

physostigma, 148 

sodium hyposulphite, 411 

strychnin, 144 
treatment, 562 
Stomach, ulcer of 

anesthesin, 157 

bismuth subnitrate, 375 

cerium oxalate, 170 

cocain, 88 

creosote, 286 

hydrocyanic acid, 160 

magnesia, 200 

orthoform, 156 

silver nitrate, 372 

sodium bicarbonate, 172 
treatment, 559 
Stomachics, 174 
Stomatitis 

boric acid. 412 

copper sulphate, 367 

hydrogen dioxid, 409 

myrrh, 250 

potassium chlorate, 230 

permanganate (gangrenous), 
409 

rhus glabra, 359 

silver nitrate, 372 

sodium bicarbonate, 172 
hyposulphite (thrush), 411 
treatment, 551 
Stools, disinfection of, 386 
Stovain, 157 
Stramonium, 80 
Strictures 

thiosinamin, 444 
Strontii bromidum, 115 
iodidum, 316 



6j2 



INDEX. 



Strontii salicylas, 399 
Strophanthinum, 53 
Strophanthus, 53; as a diuretic, 222 
Strychnin, 141. See Nux Vomica. 
Strychnina, 141 
Strychnin-poisoning 

amyl nitrite, 70 

chloral, 103 

physostigma, 146 

potassium bromid, 113 
treatment, 143 
Stupes, turpentine, 237 
Stypticin, 380 
Sudorihcs, 257 
Sugar, fruit, 473 

milk, 473 
Sulphonal, 107 
Sulphonethylmethan, 108 
Sulphonmethan, 97 
Sulphur, 200 
Sulphurated lime, 340 
Sulphuric acid, 448 
Sumac, 359 
Sumbul, 139 

Sunstroke. See Thermic fever. 
Suppositories, 28 
Suprarenal extract, 68 

gland (see also Adrenalin): as a cir- 
culatory stimulant, 66 
glands, desiccated, 68 
Suprarenin, 66 

Sylvester's method in asphyxia, 73 
Sweating, excessive. See Night- 
sweats. 
Syncope 

alcohol, 47 

ammonia, 42 

digitalis, 50 

ether, 57 
Synovitis 

blisters, 441 

blue ointment, 327 

dry heat, 495 

iodin, 318 

local bloodletting, 503 

massage, 486 
Syphilis. See also Mucous patches, 
Ulcers, venereal, and Warts. 

atoxyl, 312 

cod-liver oil, 304 

ferrous iodid, 295 

gold and sodium chlorid, 336 

mercurials, 324 

potassium chlorate, 231 
iodid, 314 
Syrupi, 21 
Syrups, 21 



Tabell^e, 28 

Tablets, 28 

Tachycardia. See Palpitation. 

Talc, Venetian, 466 

Talcum, 466 

Tallerman apparatus for applying dry 

heat, 495 
Tamarindus, 198 
Tanacetum, 251 
Tannalbin, 356 
Tannigen, 356 
Tannin, 354 
Tannoform, 356 
Tansy, 251 
Tapeworm 

thymol, 392, 427 
treatment, 422 
Tar, 287 

camphor, 394 
Taraxacum, 177 

Tartar emetic, 271; as an emetic, 167 
Tellurium, 265 
Terebenum, 289 
Terebinthina, 236 
Terpin hydrate, 289 
Terpinol, 289 
Testis, 345 
Tetanus 

amyl nitrite, 70 

antitoxin, 432 

carbolic acid, 389 

chloral, 103 

chloroform, 126 

magnesium sulphate, 217 

opium, 97 

paraldehyd, 109 

physostigma, 147 

potassium bromid, 113 
treatment, 535 
Tetany 

calcium chlorid, 383 
Tetramethylthionin hydrochlorid, 420 
Tetranitrol, 72 
Tetronal, 109 
Thalii acetas, 266 
Thebain, 91 
Theobromina, 223 
Theocin, 223 
Theophyllin, 223 
Therapeutics, definition of, 17 
Thermic fever 

cold bath, 493 

enemata of ice-water, 499 

hypodermoclysis, 496 

venesection, 504 
Thiocol, 287 
Thiol, 336 
Thiosinamin, 443 
Thymol, 392 



INDEX. 



6/3 



Thymol iodid, 321 
Thymolis iodidum, 321 
Thymus gland, 344 
Thyroid extract, 341 

glands, desiccated, 341 
Thyroidism, 342 

Tic douloureux. See Neuralgia. 
Tinctures, 22 
Tinnitus aurium 

cimicifuga, 138 

gelsemium, 149 

hydrobromic acid, 116 

pilocarpin, 261 
Toadstool-poisoning 

atropin, 80 
Toe-nail, ingrowing 

potassa, 455 
Tonics, 289 
Tonsillitis 

aconite, 62 

calx sulphurata, 340 

guaiac, 338 

ice-poultice, 492 

salophen, 398 

sodii benzoate, 278 
treatment, 553 
Toothache 

chloral camphor, 103 
menthol, 158 

creosote, 285 

oil of cloves, 188 
Torticollis. See Wry-neck. 
Toxaphore groups, 429 
Toxins, 428 
Tragacantha, 460 
Traumaticin, 469 
Trinitrin, 71. See Nitroglycerin. 
Trional, 108 
Triturates, 28 
Triturationes, 28 
Troches, 28 
Tropococain, 155 
Tuberculin, 435 

Tuberculosis, pulmonary. See also 
Night-sweats. 

alcohol, 47 

arsenic, 310 

blisters, 441 

calcium hypophosphite, 302 

cannabis indica (cough), 10 1 

chloroform (cough), 127 

cinnamic acid, 190 

codein (cough), 99 

cod-liver oil, 304 

creosote, 284 
carbonate, 285 

eucalyptol, 281 

guaiacol carbonate, 286 

heroin (cough), 99 

43 



Tuberculosis, pulmonary 

hydrocyanic acid (cough), 160 

iodoform, 321 

mercuric succinimid, 334 

oil of myrtle, 281 

opium (cough), 96 

orexin (anorexia), 179 

strychnin, 143 

terebene, 288 
treatment, 592 
Turkish bath, 494 
Turlington's balsam, 277 
Turpentine, 236 
Turpeth mineral, 167 
Tympanites. See also Flatulence. 

asafetida, 134 

carminatives, 184 

gastro-intestinal antiseptics, 386 

oil of turpentine, 237 

physostigma, 148 
Typhoid fever 

alcohol, 47 

beta-naphthol, 395 

caffein, 55 

camphor, 132 

cold, 492 

intestinal antiseptics, 386 

lime-water, 173 

musk, 137 

physostigma, 148 

strychnin, 143 

turpentine, 237 
treatment, 509 
Typhoid vaccine, 437 
Typhus fever 
treatment, 514 



Ulcers 

anesthesin (painful), 157 
burnt alum (exuberant granula- 
tions), 361 
charcoal (foul), 413 
chloretone (painful), 106 
citrine ointment (indolent), 332 
continuous warm baths (phage- 
denic), 495 
copaiba (indolent), 235 
copper sulphate (indolent), 367 
formaldehydum, 404 
glutol, 404 

hydrogen dioxid, 408 
iodoform, 319 
lead-plaster, 365 
orthoform (painful), 156 
potassium permanganate (foul), 

409 
resin cerate (indolent), 238 
silver nitrate, 371 



674 



INDEX. 



Ulcers 

trichloracetic acid (tuberculous), 

45i 

Unna's gelatin dressing (indolent), 
382 

zinc oxid (acute), 368 
Ulcers, corneal 

calomel, 330 
Ulcers, venereal 

black wash, 331 

carbolic acid, pure, 389 

mercuric nitrate, 332 

nitric acid, 450 

sulphuric acid, 449 

trichloracetic acid, 451 

yellow wash, 330 
Ulmus, 451 

Uncinariasis. See Hookworm dis- 
ease. 
Unguenta, 28 
Uranii nitras, 341 
Uremia 

amyl nitrite, 70 

bleeding, 503 

chloral, 103 

chloroform, 126 

croton oil, 211 

elaterium, 215 

enteroclysis, 499 

hot baths, 495 

hypodermoclysis, 496 

infusion, 496 

lumbar puncture, 508 

opium, 97 

pilocarpin, 260 

potassium bromid, 113 
treatment, 617 
Urethane, no 

Urethritis. See Gonorrhea. 
Uric-acid solvents, 243 
Urine, incontinence of 

belladonna, 78 

strychnin, 144 
Urosin, 244 
Urotropin, 404 
Urticaria 

boric acid, 412 

calcium chlorid, 383 

camphor, 133 

hydrocyanic acid, 160 

ichthyol, 335 
Ustilago maydis, 257 
Uterus, cancer of 

oil of turpentine, 238 

opium, 95 

potassium permanganate, 409 
Uterus, fibroma of 

ergot, 255 

thyroid gland, 343 



Uterus, inertia of 

ergot, 255 
quinin, 256, 419 
strychnin, 145 
Uva ursi, 240 



Vaccination, 528 
Vaccines, 428 

bubonic plague, 436 
cholera, 436 
typhoid, 437 
Valeriana, 135 
Vallet's mass, 292 
Valvular disease. See Endocarditis, 

chronic. 
Variola 

treatment, 528 
Vaselin, 465 
Vasoconstrictors, 66 
Vasodilators, 66 
Vegetable cathartic pills, 212 
Venesection, 503 

Veratrina, 159; as a circulatory depres- 
sant, 63 
Veratrum, 63; as a poison, 64 
Vermifuges, 422 
Veronal, in 
Vesicants, 438 
Viburnum prunifolium, 140 
Vienna paste, 455 
Vina, 24 
Vinegar, 451 
Vinegars, 19 
Vitriol, blue, 366 
green, 294 
oil of, 448 
white, 367 
Vleminckx's solution of, 341 
Volatile oils, definition of, 18 
Vomiting, excessive 

aconite, 63 

arsenic, 310 

bismuth subnitrate, 375 

blister, 441 

carbolic acid, 390 

cerium oxalate, 170 

cocain, 88 

creosote, 284 

hydrocyanic acid, 160 

ipecac, 270 

lime-water, 172 

menthol, 170 

nux vomica, 145 

opium, 96 

orexin, 179 

potassium bromid, 114 
treatment, 168 



INDEX. 



675 



Wahoo, 202 

Warburg's tincture, 422 

Warts 

acetic acid, 451 
caustic potash, 455 

soda, 455 
chromic acid, 452 
salicylic acid, 398 
sodium ethylate, 456 
trichloracetic acid, 451 

Warts, venereal 
calomel, 330 
carbolic acid, pure, 389 
chromic acid, 452 
trichloracetic acid, 451 

Wash, black, 331 
yellow, 330 

Waters, 19 

Whiskey, 43 

White hellebore, 63 
oak, 360 
precipitate, 332 

Whooping-cough 
amyl nitrite, 70 
antipyrin, 350 
asafetida, 134 
belladonna, 78 
bromoform, 116 
camphor, 132 
chloral, 103 
chloroform, 126 
gelsemium, 149 
hyoscyamus, 81 
oil of amber, 140 
potassium bromid, 113 
quinin, 419 
treatment, 532 

Wild cherry, 178 

Wines, 24, 44 

Wintergreen, oil of, 399 



Witch-hazel, 360 
Wool-fat, 464 

hydrous, 464 
Worms, intestinal 

treatment, 422 
Wormseed, American, 426; Levant, 425 
Writer's cramp 
treatment, 486 
Wry-neck 

atropin, 78 
capsicum, 186 
electricity, 483 
gelsemium, 149 
hyoscyamin, 82 



Xeroform, 391 

Yellow fever 

treatment, 530 
Yellow jasmine, 149 

wash, 330 
Yerba santa, 471 
Yohimbin, 245 
Young's rule for dosage, 38 

Zea, 242 

Zinci acetas, 368 

carbonas, 369 

chloridum, 369; as an escharotic, 

457 

oxidum, 368 

phenolsulphonas, 390 

phosphidum, 301 

sulphas, 367; as an emetic, 167 

valeras, 135 
Zincum, 367 
Zingiber, 189 



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have been selected with great care, keeping constantly in mind the practical needs of the 
general practitioner. These beautiful pictures are so true to nature that their study is 
equivalent to actual clinical observation. The editor, Dr. Isaac A. Abt, has added all new 
methods of treatment. 

Johns Hopkins Hospital Bulletin 

" The entire field has been covered. With the excellent plates, it will be found of real 
value to both students and practitioners." 

Lewis' Anatomy and Physiology 

Anatomy and Physiology for Nurses. By LeRoy Lewis, M.D., 
Surgeon to and Lecturer on Anatomy and Physiology for Nurses at the 
Lewis Hospital, Bay City, Michigan. i2mo of 347 pages, with 146 
illustrations. Cloth, $1.75 net. 

A demand for such a work as this, treating the subjects from the nurses' point of view, 
has long existed. Dr. Lewis has based the plan and scope of this work on the methods 
employed by him in teaching these branches, making the text unusually simple and clear. 

The Nurses Journal of the Pacific Coast 

" It is not in any sense rudimentary, but comprehensive in its treatment of the subjects 
in hand. The application of the knowledge of anatomy in the care of the patient is 
emphasized." 

Friedenwald and Ruhrah's Dietetics New (2d* Edition 

Dietetics for Nurses. By Julius Friedenwald, M. D., Professor 
of Diseases of the Stomach, and John Ruhrah, M. D., Professor of 
Diseases of Children, College of Physicians and Surgeons, Baltimore. 
1 21T10 volume of 395 pages. Cloth, $1.50 net. 

This work has been prepared to meet the needs of the nurse, both in the training 
school and after graduation. It aims to give the essentials of dietetics, considering briefly 
the physiology of digestion and the various classes of foods and the part they play in 
nutrition. 

American Journal of Nursing 

" It is exactly the book for which nurses and others have long and vainly sought. A 
simple manual of dietetics, which does not turn into a cook-book at the end of the first 
or second chapter. 



INSANITY AND HYGIENE. 



Brower and Bannister 
on Insanity 

A Practical Manual of Insanity. For the Student and General 
Practitioner. By Daniel R. Brower, A.M., M.D., LL. D., Professor 
of Nervous and Mental Diseases in Rush Medical College, in affiliation 
with the University of Chicago ; and Henry M. Bannister, A. M., 
M. D., formerly Senior Assistant Physician, Illinois Eastern Hospital 
for the Insane. Handsome octavo of 426 pages, with a number of 
full-page inserts. Cloth, $3.00 net. 

FOR STUDENT AND PRACTITIONER 

This work, intended for the student and general practitioner, is an intelligible, 
up-to-date exposition of the leading facts of psychiatry, and will be found of in- 
valuable service, especially to the busy practitioner unable to yield the time for a 
more exhaustive study. The work has been rendered more practical by omitting 
elaborate case records and pathologic details, as well as discussions of speculative 
and controversial questions. 

American Medicine 

" Commends itself for lucid expression in clear-cut English, so essential to the student in 
any department of medicine. . . . Treatment is one of the best features of the book, and for 
this aspect is especially commended to general practitioners." 



Bergey's Hygiene 



The Principles of Hygiene: A Practical Manual for Students, 
Physicians, and Health Officers. By D. H. Bergey, A. M., M. D., 
Assistant Professor of Bacteriology in the University of Pennsylvania. 
Octavo volume of 536 pages, illustrated. Cloth, $3.00 net. 

JUST READY— THE NEW (3d) EDITION 

This book is intended to meet the needs of students of medicine in the 
acquirement of a knowledge of those principles upon which modern hygienic 
practises are based, and to aid physicians and health officers in familiarizing 
themselves with the advances made in hygiene and sanitation in recent years. 
This new third edition has been very carefully revised, and much new matter 
added, so as to include the most recent advancements. 

Buffalo Medical Journal 

" It will be found of value to the practitioner of medicine and the practical sanitarian ; and 
students of architecture, who need to consider problems of heating, lighting, ventilation, water 
supply, and sewage disposal, may consult it with profit." 



SAUNDERS' BOOKS ON 



Friihwald and WestcottV 
Diseases of Children 



Diseases of Children. A Practical Reference Book for Students 
and Practitioners. By Professor Dr. Ferdinand Fruhwald, of 
Vienna. Edited, with additions, by Thompson S Westcott, M. D., 
Associate in Diseases of Children, University of Pennsylvania. Octavo 
volume of 533 pages, containing 176 illustrations. Cloth, $4.50 net. 

ARRANGED ALPHABETICALLY 

This work represents the author's twenty years' experience, and is intended 
as a practical reference work for the student and practitioner. With this refer- 
ence feature in view, the individual diseases have been arranged alphabetically. 
The prophylactic, therapeutic, and dietetic treatments are elaborately discussed. 
The practical value of the book has been considerably enhanced by the many 
excellent illustrations. 
E. H. Bartley, M. D., 

Professor of Pediatrics, Chemistry, and Toxicology, Long Island College Hospital, New York, 
"It is a new idea, which ought to become popular because of the alphabetic arrangement. 
Its title expresses just what it is — a ready reference hand-book." 



Ruhrah's 
Diseases of Children 

A Manual of Diseases of Children. By John Ruhrah, M. D., 
Professor of Diseases of Children, College of Physicians and Surgeons, 
Baltimore. i2mo of 425 pages, fully illustrated. Flexible leather, 
$2.00 net. 

THE NEW (2d) EDITION 

In revising this work for the second edition Dr. Ruhrah has carefully 
incorporated all the latest knowledge on the subject. All the important facts 
are given concisely and explicitly, the therapeutics of infancy and childhood 
being outlined very carefully and clearly. There are also directions for dosage 
and prescribing, and many useful prescriptions are included. The entire work 
is amply illustrated with practical illustrations. A valuable aid consists in the 
references to pediatric literature. 

American Journal of the Medical Sciences 

" Treatment has been satisfactorily covered, being quite in accord with the best teaching, 
yet withal broadly general and free from stock prescriptions." 



CHILDREN AND HYGIENE. 13 

Griffith's Care of the Baby 

The Care of the Baby. By J. P. Cromer Griffith, M. D., Clinical 
Professor of Diseases of Children, University of Penn. ; Physician to the 
Children's Hospital, Phila. i2mo, 455 pp. Illustrated. Cloth, $1.50 net. 

THE NEW (4th) EDITION 

The author has endeavored to furnish a reliable guide for mothers. He has 
made his statements plain and easily understood, in the hope that the volume 
may be of service not only to mothers and nurses, but also to students and practi- 
tioners whose opportunities for observing children have been limited. 

New York Medical Journal 

" We are confident if this little work could find its way into the hands of every trained 
nurse and of every mother, infant mortality would be lessened by at least fifty per cent." 

Crothers' Morphinism 

Morphinism and Narcomania from Opium, Cocain, Ether, Chloral, 
Chloroform, and other Narcotic Drugs ; also the Etiology, Treatment, 
and Medicolegal Relations. By T. D. Crothers, M. D., Superintendent 
of Walnut Lodge Hospital, Hartford, Conn. Handsome i2mo of 351 
pages. Cloth, $2.00 net. 

The Lancet, London 

"An excellent account of the various causes, symptoms, and stages of morphinism, the 
discussion being throughout illuminated by an abundance of facts of clinical, psychological, and 
social interest." 

Ai kens' 

Secondary Studies for Nurses 

Secondary Studies for Nurses. By Charlotte A. Aikens, 
formerly Director of Sibley Memorial Hospital, Washington, D. C. 
i2mo of 450 pages, illustrated. 

JUST READY 

This new work is written along the same lines as Miss Aikens' former work on 
" Primary Studies," to which it is a companion volume. It takes up all subjects 
taught during the second year, and takes them up in a concise, forceful way. 
The text is illustrated with helpful illustrations. 



SAUNDERS 1 BOOKS ON 



Peterson and Haines' 
Legal Medicine & Toxicology 



A Text=Book of Legal Medicine and Toxicology. Edited by 
Frederick Peterson, M. D., Professor of Psychiatry in the College 
of Physicians and Surgeons, New York ; and Walter S. Haines, 
M. D., Professor of Chemistry, Pharmacy, and Toxicology, Rush 
Medical College, in affiliation with the University of Chicago. Two 
imperial octavo volumes of about 750 pages each, fully illustrated. 
Per volume: Cloth, $5.00 net; Sheep or Half Morocco, $6.50 net. 
Sold by Subscription. 

IN TWO VOLUMES— BOTH VOLUMES NOW READY 

The object of the present work is to give to the medical and legal professions 
a comprehensive survey of forensic medicine and toxicology in moderate compass. 
This, it is believed, has not been done in any other recent work in English. Under 
' ' Expert Evidence ' ' not only is advice given to medical experts, but suggestions 
are also made to attorneys as to the best methods of obtaining the desired infor- 
mation from the witness. An interesting and important chapter is that on ' * The 
Destruction and Attempted Destruction of the Human Body by Fire and Chemi- 
cals." A chapter not usually found in works on legal medicine is that on "The 
Medicolegal Relations of the X-Rays. " This section will be found of unusual im- 
portance. The responsibility of pharmacists in the compounding of prescriptions, 
in the selling of poisons, in substituting drugs other than those prescribed, etc., 
furnishes a chapter of the greatest interest to every one concerned with questions 
of medical jurisprudence. Also included in the work is the enumeration of the 
laws of the various states relating to the commitment and retention of the insane. 



OPINIONS OF THE MEDICAL PRESS 



Medical News, New York 

" It not only fills a need from the standpoint of timeliness, but it also sets a standard of 
what a text-book on Legal Medicine and Toxicology should be." 

Columbia Law Review 

" For practitioners in criminal law and for those in medicine who are called upon to give 
court testimony in all its various forms ... it is extremely valuable." 

Pennsylvania Medical Journal 

" If the excellence of this volume is equaled by the second, the work will easily take rank 
as the standard text-book on Legal Medicine and Toxicology." 



LEGAL MEDICINE. 15 



Draper's Legal Medicine 

A Text=Book of Legal Medicine. By Frank Winthrop Draper, 
A. M., M. D., Professor of Legal Medicine in Harvard University, Bos- 
ton; Medical Examiner of the County of Suffolk, Massachusetts, etc. Octavo 
volume of 573 pages, fully illustrated. Cloth, $4.00 net; Half Morocco, 
$5.50 net. 

Hon. Olin Bryan, LL. B. 

Professor of Medical furisprudence, Baltimore Medical College 

" A careful reading of Draper's Legal Medicine convinces me of the excellent character 
of the work. It is comprehensive, thorough, and must, of a necessity, prove a splendid 
acquisition to the libraries of those who are interested in medical jurisprudence." 

Chapman's Medical Jurisprudence Third Edition 

Medical Jurisprudence, Insanity, and Toxicology. By Henry C. 
Chapman, M. D., Professor of Institutes of Medicine and Medical Juris- 
prudence in Jefferson Medical College, Philadelphia. i2mo of 329 pages, 
fully illustrated. Cloth, $1.75 net. 

Medical Record, New York 

" The manual is essentially practical, and is a useful guide for the general practitioner, 
besides possessing literary merit." 

Hofmann and Peterson's Legal Medicine HandXiwes 

Atlas of Legal Medicine. By Dr. E. von Hofmann, of Vienna. 
Edited by Frederick Peterson, M. D., Professor of Psychiatry in the 
College of Physicians and Surgeons, New York. With 120 colored figures 
on 56 plates and 193 half-tone illustrations. Cloth, $3.50 net. 

Jakob and Fisher's Nervous System 

and itS Diseases In Saunders' Hand-Atlases 

Atlas and Epitome of the Nervous System and its Diseases. By 

Professor Dr. Chr. Jakob, of Erlangen. From the Second Revised 
German Edition. Edited, with additions, by Edward D. Fisher, M. D., 
Professor of Diseases of the Nervous System, University and Belle vue 
Hospital Medical College, New York. With 83 plates and copious text. 
Cloth, $3.50 net. 

Abbott's Transmissible Diseases second Edition 

The Hygiene of Transmissible Diseases : Their Causes, Modes of Dis- 
semination, and Methods of Prevention. By A. C. Abbott, M. D., Pro- 
fessor of Hygiene and Bacteriology, University of Pennsylvania. Octavo of 
351 pages, illustrated. Cloth, $2.50 net. 



1 6 S A l/A^DERS' BOOKS ON CHILDREN. 

American Pocket Dictionary sixth Edition— just Ready 

American Pocket Medical Dictionary. Edited by W. A. New- 
man Dorland, M. D., Assistant Obstetrician to the Hospital of the 
University of Pennsylvania. Containing the pronunciation and defini- 
tion of the principal words used in medicine and kindred sciences, with 
64 extensive tables. Handsomely bound in flexible leather, with gold 
edges, #1.00 net ; with patent thumb index, £1.25 net. 

" I can recommend it to our students without reserve." — J. H. HOLLAND, M. D., Dean 
of the Jefferson Medical College, Philadelphia. 

Morrow's Immediate Care of Injured 

Immediate Care of the Injured. By Albert S. Morrow, M. D., 
Attending Surgeon to the New York City Hospital for the Aged and 
Infirm. Octavo of 340 pages, with 238 illustrations. Cloth, $2.50 net. 

Dr. Morrow's book on emergency procedures is written in a definite and decisive style, 
the reader being told just what to do in every emergency. It is a practical book for every 
day use, and the large number of excellent illustrations can not but make the treatment to 
be pursued in any case clear and intelligible. Physicians and nurses will find it indispensible. 

Powell's Diseases of Children Third Edition, Revised 

Essentials of the Diseases of Children. By William M. Powell, 
M. D. Revised by Alfred Hand, Jr., A. B., M. D., Dispensary 
Physician and Pathologist to the Children's Hospital, Philadelphia. 
i2mo volume of 259 pages. Cloth, $1.00 net. In Saunders'' 
Question- Compend Series. 

Shaw on Nervous Diseases and Insanity Fourth edition 

Essentials of Nervous Diseases and Insanity : Their Symptoms 
and Treatment. A Manual for Students and Practitioners. By the late 
John C. Shaw, M. D., Clinical Professor of Diseases of the Mind and 
Nervous System, Long Island College Hospital, New York. i2mo of 
204 pages, illustrated. Cloth, #1.00 net. In Saunders' Question- Com- 
pend Series. 

" Clearly and intelligently written ; we have noted few inaccuracies and several sug- 
gestive points. Some affections unmentioned in many of the large text-books are noted/ 
— Boston Medical and Surgical Journal. 

Starr's Diets for Infants and Children 

Diets for Infants and Children in Health and in Disease. By 
Louis Starr, M. D., Consulting Pediatrist to the Maternity Hospital, 
Philadelphia. 230 blanks (pocket-book size). Bound in flexible leather, 
$1.25 net. 

Grafstrom's Mechano-Therapy second Revised Edition 

A Text-book of Mechano-therapy (Massage and Medical Gymnas- 
tics). By Axel V. Grafstrom, B. Sc, M. D., Attending Physician to 
the Gustavus Adolphus Orphange, Jamestown, New York. i2mo, 200 
pages, illustrated. Cloth, $1.25 net. 



